MEDICARE: MR. HOWARD RANDOLPH ELLISON II OPTICIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	008765	NY

General Provider Information

NPI Number	:	1023325107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HOWARD RANDOLPH ELLISON II OPTICIAN

Provider Business Mailing Address
First Line	:	132 E FORDHAM RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-5408
Country	:	US
Telephone Number	:	718-561-1600
Fax Number	:	718-561-1611

Provider Business Practice Location Address
First Line	:	132 E FORDHAM RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-5408
Country	:	US
Telephone Number	:	718-561-1600
Fax Number	:	718-561-1611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2010
Last Update Date	:	09/09/2010

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