Healthcare Provider Details

I. General information

NPI: 1609382993
Provider Name (Legal Business Name): MR. ROBERT BECERRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6438 BASILE ROWE
EAST SYRACUSE NY
13057-3900
US

IV. Provider business mailing address

6438 BASILE ROWE
EAST SYRACUSE NY
13057-3900
US

V. Phone/Fax

Practice location:
  • Phone: 315-434-9168
  • Fax: 315-434-9182
Mailing address:
  • Phone: 315-434-9168
  • Fax: 315-434-9182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number009442-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: