Healthcare Provider Details

I. General information

NPI: 1972583128
Provider Name (Legal Business Name): SANDRA JEAN TARASEVICH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2006
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 ROUTE 202 BLDG A, 2ND FLOOR - MAILBOX #7
SOMERS NY
10589-3207
US

IV. Provider business mailing address

340 ROUTE 202 BLDG A, 2ND FLOOR - MAILBOX #7
SOMERS NY
10589-3207
US

V. Phone/Fax

Practice location:
  • Phone: 914-669-9144
  • Fax: 914-669-1035
Mailing address:
  • Phone: 914-669-9144
  • Fax: 914-669-1035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT005613
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: