Healthcare Provider Details

I. General information

NPI: 1679576102
Provider Name (Legal Business Name): PAUL PATSALIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6834 3RD AVE
BROOKLYN NY
11220-5803
US

IV. Provider business mailing address

6834 3RD AVE
BROOKLYN NY
11220-5803
US

V. Phone/Fax

Practice location:
  • Phone: 718-680-3270
  • Fax: 718-680-4918
Mailing address:
  • Phone: 718-680-3270
  • Fax: 718-680-4918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1195
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT004810-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: