Provider Demographics
NPI:1194329938
Name:VISION VIBRANT MEDICINE PLLC
Entity type:Organization
Organization Name:VISION VIBRANT MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:PAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-714-8977
Mailing Address - Street 1:86 MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-8806
Mailing Address - Country:US
Mailing Address - Phone:914-440-3210
Mailing Address - Fax:
Practice Address - Street 1:86 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-8806
Practice Address - Country:US
Practice Address - Phone:914-440-3210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-23
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300215458OtherPTAN
NY244649OtherLICENSE NUMBER