MEDICARE: IVONA LEOPOLDINA KULUSIC O.D.

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	152W00000X	Optometrist	T005637	NY

General Provider Information

NPI Number	:	1114358058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVONA LEOPOLDINA KULUSIC O.D.

Provider Business Mailing Address
First Line	:	2058 LEXINGTON AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-1732
Country	:	US
Telephone Number	:	212-360-7422
Fax Number	:

Provider Business Practice Location Address
First Line	:	2058 LEXINGTON AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-1732
Country	:	US
Telephone Number	:	212-360-7422
Fax Number	:

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

Provider Enumeration Date	:	12/03/2013
Last Update Date	:	12/03/2013

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