Provider Demographics
NPI:1952391708
Name:FRIED, JACK (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:FRIED
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 1:64 MIDDLE NECK RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2357
Mailing Address - Country:US
Mailing Address - Phone:516-482-0129
Mailing Address - Fax:516-829-3126
Practice Address - Street 1:64 MIDDLE NECK RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2357
Practice Address - Country:US
Practice Address - Phone:516-482-0129
Practice Address - Fax:516-829-3126
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005890-1152W00000X
FLOPC3468152W00000X
MAOPT4060152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400007070Medicare PIN
NYC57141Medicare ID - Type UnspecifiedPROVIDER ID#
NYU75063Medicare UPIN