Healthcare Provider Details

I. General information

NPI: 1164423448
Provider Name (Legal Business Name): THEODORE N ISSEKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: THEODORE N ISSEKS MD

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5518 STATE ROUTE 55
LIBERTY NY
12754
US

IV. Provider business mailing address

5518 STATE ROUTE 55
LIBERTY NY
12754
US

V. Phone/Fax

Practice location:
  • Phone: 845-292-3011
  • Fax: 845-292-1821
Mailing address:
  • Phone: 845-292-3011
  • Fax: 845-292-1821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number117110
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: