Healthcare Provider Details

I. General information

NPI: 1336294636
Provider Name (Legal Business Name): VLADIMIR DVORETSKY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/12/2011
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:
Mailing address:
  • Phone: 212-923-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number007109
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: