MEDICARE: KRISTIN ANN PROTOSOW OPTOMETRIST, OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WL0500X	Low Vision Rehabilitation Optometrist	TUV007254-1	NY

General Provider Information

NPI Number	:	1063688547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN ANN PROTOSOW OPTOMETRIST, OD

Provider Business Mailing Address
First Line	:	624 HAWKINS AVE.
Second Line	:	SUITE 1
City	:	RONKONKOMA
State	:	NY
Zip	:	11779
Country	:	US
Telephone Number	:	631-588-5100
Fax Number	:	631-588-5185

Provider Business Practice Location Address
First Line	:	624 HAWKINS AVE
Second Line	:	SUITE 1
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-2375
Country	:	US
Telephone Number	:	631-588-5100
Fax Number	:	631-588-5185

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	11/18/2011

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