MEDICARE: DR. MARK RICHARD SUKOENIG O.D.

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	152W00000X	Optometrist	TU003680-1	NY
2	152WL0500X	Low Vision Rehabilitation Optometrist	TU003680-1	NY
3	152W00000X	Optometrist	TUV003680	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TU003680-1	OTHER	NY	NY OPTOMETRY LICENSE #

General Provider Information

NPI Number	:	1407848724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK RICHARD SUKOENIG O.D.

Provider Business Mailing Address
First Line	:	9537 DESTINYUSA DRIVE
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13204-9501
Country	:	US
Telephone Number	:	315-474-8490
Fax Number	:	315-474-8676

Provider Business Practice Location Address
First Line	:	9537 DESTINYUSA DRIVE
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13204-9501
Country	:	US
Telephone Number	:	315-474-8490
Fax Number	:	315-474-8676

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	04/14/2016

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