Healthcare Provider Details

I. General information

NPI: 1043326424
Provider Name (Legal Business Name): TAMARA STOCKWIN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BRENTWOOD DR SUITE A
ITHACA NY
14850-1865
US

IV. Provider business mailing address

10 BRENTWOOD DR SUITE A
ITHACA NY
14850-1865
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-5599
  • Fax: 607-257-3972
Mailing address:
  • Phone: 607-257-5599
  • Fax: 607-257-3972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV0059541
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: