Healthcare Provider Details

I. General information

NPI: 1548641475
Provider Name (Legal Business Name): AMANDA MARIE SCALISE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8024 STATE ROUTE 12
BARNEVELD NY
13304-2512
US

IV. Provider business mailing address

8024 STATE ROUTE 12
BARNEVELD NY
13304-2512
US

V. Phone/Fax

Practice location:
  • Phone: 315-896-3900
  • Fax: 315-896-3905
Mailing address:
  • Phone: 315-896-3900
  • Fax: 315-896-3905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV008266
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: