Healthcare Provider Details

I. General information

NPI: 1285702712
Provider Name (Legal Business Name): VISTA OPTOMETRY AND OPHTHALMIC DISPENSING CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 W 181ST ST
NEW YORK NY
10033-4516
US

IV. Provider business mailing address

817 W 181ST ST
NEW YORK NY
10033-4516
US

V. Phone/Fax

Practice location:
  • Phone: 212-923-2020
  • Fax: 212-923-0260
Mailing address:
  • Phone: 212-923-2020
  • Fax: 212-923-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT006118
License Number StateNY

VIII. Authorized Official

Name: DR. VLADIMIR DVORETSKY
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 212-923-2020