Provider Demographics
NPI:1285245159
Name:SHLIVKO, ALEXANDER N (OD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:N
Last Name:SHLIVKO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SURF AVE APT 22R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-3547
Mailing Address - Country:US
Mailing Address - Phone:646-204-9821
Mailing Address - Fax:
Practice Address - Street 1:2250 86TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-4139
Practice Address - Country:US
Practice Address - Phone:718-714-1000
Practice Address - Fax:718-714-1036
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009186152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist