Healthcare Provider Details

I. General information

NPI: 1750334264
Provider Name (Legal Business Name): STANISLAV V ILYUSHA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 SHEEPSHEAD BAY RD
BROOKLYN NY
11235-3803
US

IV. Provider business mailing address

1612 SHEEPSHEAD BAY RD
BROOKLYN NY
11235-3803
US

V. Phone/Fax

Practice location:
  • Phone: 718-934-1123
  • Fax: 718-934-2366
Mailing address:
  • Phone: 917-803-7654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberVUT006443
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: