Provider Demographics
NPI:1700088481
Name:MATOS, GRACE (OD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MATOS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 SESAME ST
Mailing Address - Street 2:
Mailing Address - City:ROCK TAVERN
Mailing Address - State:NY
Mailing Address - Zip Code:12575-5529
Mailing Address - Country:US
Mailing Address - Phone:845-496-1094
Mailing Address - Fax:
Practice Address - Street 1:ONE NORTH GALLERIA DRIVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941
Practice Address - Country:US
Practice Address - Phone:845-845-6920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT005638-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist