MEDICARE: ALLA DYATLOV OPTICIAN

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	156FX1800X	Optician	006774-1	NY

General Provider Information

NPI Number	:	1205018488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLA DYATLOV OPTICIAN

Provider Business Mailing Address
First Line	:	139 FLATBUSH AVE
Second Line	:	ATLANTIC TERMINAL MALL
City	:	BROOKLYN
State	:	NY
Zip	:	11217-1450
Country	:	US
Telephone Number	:	718-522-3737
Fax Number	:	718-522-3894

Provider Business Practice Location Address
First Line	:	139 FLATBUSH AVE
Second Line	:	ATLANTIC TERMINAL MALL
City	:	BROOKLYN
State	:	NY
Zip	:	11217-1450
Country	:	US
Telephone Number	:	718-522-3737
Fax Number	:	718-522-3894

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

Provider Enumeration Date	:	11/29/2007
Last Update Date	:	11/29/2007

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