MEDICARE: VISTASITE OPTIQUE INC

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	261QS0132X	Ophthalmologic Surgery Clinic/Center

General Provider Information

NPI Number	:	1578052791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISTASITE OPTIQUE INC

Provider Business Mailing Address
First Line	:	4204 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10033-3706
Country	:	US
Telephone Number	:	917-261-6100
Fax Number	:	917-861-6697

Provider Business Practice Location Address
First Line	:	4204 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10033-3706
Country	:	US
Telephone Number	:	917-261-6100
Fax Number	:	917-861-6697

Authorized Official
Title or Position	:	OD
Name	:	VLADIMIR DVORETSKY
Credential	:	OD
Telephone Number	:	212-433-0136

Provider Enumeration Date	:	05/02/2018
Last Update Date	:	03/15/2021

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Directions to “VISTASITE OPTIQUE INC ” Practice Location

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