Provider Demographics
NPI:1063759082
Name:DAVIDSON, ILYA (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:ILYA
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5852
Mailing Address - Country:US
Mailing Address - Phone:718-624-6700
Mailing Address - Fax:718-624-6701
Practice Address - Street 1:324 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5852
Practice Address - Country:US
Practice Address - Phone:718-624-6700
Practice Address - Fax:718-624-6701
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0088961156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1760727101OtherBUSINESS NPI