Healthcare Provider Details

I. General information

NPI: 1639740772
Provider Name (Legal Business Name): INDIGO ENSIGN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 W BURNSIDE AVE
BRONX NY
10453-4019
US

IV. Provider business mailing address

38 W BURNSIDE AVE
BRONX NY
10453-4019
US

V. Phone/Fax

Practice location:
  • Phone: 718-280-1332
  • Fax: 718-717-1441
Mailing address:
  • Phone: 718-280-1332
  • Fax: 718-717-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number009342-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: