Basic Information
| Provider Information | |||||||||
| NPI: | 1194815316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORELICK | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1953 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH BALDWIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115102820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168646298 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 159-03 JAMAICA AVE | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554233700 | ||||||||
| FaxNumber: | 6314993062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | UT004997-1 | NY | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | TUV004997-1 | NY | N | Eye and Vision Services Providers | Optometrist |
No ID Information.