=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497857783
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE DI TUSA OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2006
-----------------------------------------------------
Last Update Date | 12/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4235 VETERAN DR
-----------------------------------------------------
City | GENESEO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14454-9442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-243-3940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 59 DUNDAS DR
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14625-1370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-880-1437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | UT005445
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------