Provider Demographics
NPI:1215622691
Name:GRAHAM, ZACHARY WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:WILLIAM
Last Name:GRAHAM
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 1:425 2ND ST
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-2917
Mailing Address - Country:US
Mailing Address - Phone:631-747-0676
Mailing Address - Fax:
Practice Address - Street 1:2094 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548
Practice Address - Country:US
Practice Address - Phone:914-737-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYTUV009788152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program