Provider Demographics
NPI:1285884031
Name:GANTMAN, MITCHELL (OPTICIAN)
Entity type:Individual
Prefix:MS
First Name:MITCHELL
Middle Name:
Last Name:GANTMAN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 UNION TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040
Mailing Address - Country:US
Mailing Address - Phone:516-352-2316
Mailing Address - Fax:516-352-4568
Practice Address - Street 1:1562 UNION TURNPIKE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040
Practice Address - Country:US
Practice Address - Phone:516-352-2316
Practice Address - Fax:516-352-4568
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5042156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1080240001Medicare NSC