Healthcare Provider Details

I. General information

NPI: 1336711373
Provider Name (Legal Business Name): MITCHELL JAY STYCZYNSKI OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2021
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 LYME RD STE 201
HANOVER NH
03755-1260
US

IV. Provider business mailing address

45 LYME RD STE 201
HANOVER NH
03755-1260
US

V. Phone/Fax

Practice location:
  • Phone: 603-643-2140
  • Fax:
Mailing address:
  • Phone: 603-643-2140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number030.0133942
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1059
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: