Provider Demographics
NPI:1285721886
Name:GRISAR, MARK HOWARD (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:HOWARD
Last Name:GRISAR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:1765 CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-2828
Practice Address - Country:US
Practice Address - Phone:914-961-1004
Practice Address - Fax:914-961-7636
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT004040-01152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T49096Medicare UPIN
NYC33281Medicare ID - Type Unspecified