Provider Demographics
NPI:1952372245
Name:PERSAK, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:PERSAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4403
Mailing Address - Country:US
Mailing Address - Phone:631-422-1110
Mailing Address - Fax:631-422-1916
Practice Address - Street 1:360 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4403
Practice Address - Country:US
Practice Address - Phone:631-422-1110
Practice Address - Fax:631-422-1916
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150488207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01019938Medicaid
NYA62947Medicare UPIN
NY01019938Medicaid
0758350001Medicare NSC