Provider Demographics
NPI:1669522900
Name:RAY, JOHN S (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:RAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 DRIVING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1057
Mailing Address - Country:US
Mailing Address - Phone:315-331-8921
Mailing Address - Fax:315-331-8231
Practice Address - Street 1:1210 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1057
Practice Address - Country:US
Practice Address - Phone:585-394-2020
Practice Address - Fax:585-394-9261
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYTW006745152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02649705Medicaid
NYU082623Medicare UPIN