Provider Demographics
NPI:1427115633
Name:COOPER GROSSBERG, AMY (OD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:COOPER GROSSBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 OAKDALE LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1535
Mailing Address - Country:US
Mailing Address - Phone:516-621-8330
Mailing Address - Fax:
Practice Address - Street 1:4 OAKDALE LN
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1535
Practice Address - Country:US
Practice Address - Phone:516-621-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27T0000A1300152W00000X
NYT005267152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5660009Medicaid
NY01296506Medicaid
NJ785191Medicare ID - Type Unspecified
NJ5660009Medicaid