Provider Demographics
NPI:1124060751
Name:BORYSZAK, ETHAN (OD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:BORYSZAK
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 1:5683 S TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5844
Mailing Address - Country:US
Mailing Address - Phone:716-631-3860
Mailing Address - Fax:
Practice Address - Street 1:5683 S TRANSIT RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5844
Practice Address - Country:US
Practice Address - Phone:716-631-3860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006999-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1124060751OtherUNIVERA
NYNY6999OtherEYE MED
NY02748149Medicaid