Provider Demographics
NPI:1699723452
Name:PIENTKA, GREG (OD)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:
Last Name:PIENTKA
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 1:640 W BOYNTON BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-3637
Mailing Address - Country:US
Mailing Address - Phone:561-732-8088
Mailing Address - Fax:561-732-8112
Practice Address - Street 1:640 W BOYNTON BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-3637
Practice Address - Country:US
Practice Address - Phone:561-732-8088
Practice Address - Fax:561-732-8112
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC-3038152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620319100Medicaid
FLE0504OtherMEDICARE ID#
FL620319100Medicaid