Healthcare Provider Details

I. General information

NPI: 1881673184
Provider Name (Legal Business Name): MICHAEL KISELOW O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 MANHATTAN AVE GREENPOINT EYE CARE LLC
BROOKLYN NY
11222-5960
US

IV. Provider business mailing address

909 MANHATTAN AVE GREENPOINT EYE CARE LLC
BROOKLYN NY
11222-5960
US

V. Phone/Fax

Practice location:
  • Phone: 718-389-0333
  • Fax: 718-389-0040
Mailing address:
  • Phone: 718-389-0333
  • Fax: 718-389-0040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTUV006648-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number12450
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC 4148
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1346
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: