=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629208525
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LACEY DUSTIN BEDOY O.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2009
-----------------------------------------------------
Last Update Date | 11/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 454 MALCOLM X BLVD
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10037-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-368-2020
-----------------------------------------------------
Fax | 201-797-5809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 454 MALCOLM X BLVD
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10037-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-368-2020
-----------------------------------------------------
Fax | 201-797-5809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV007642-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 27OAOO620000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------