Healthcare Provider Details

I. General information

NPI: 1730199043
Provider Name (Legal Business Name): ANDREW TADDEO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 ERIE BLVD E
SYRACUSE NY
13210-1144
US

IV. Provider business mailing address

8574 BURNET RD
CLAY NY
13041-9412
US

V. Phone/Fax

Practice location:
  • Phone: 315-422-4412
  • Fax: 315-422-4690
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberC0038721
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: