Provider Demographics
NPI:1285702712
Name:VISTA OPTOMETRY AND OPHTHALMIC DISPENSING CARE PLLC
Entity type:Organization
Organization Name:VISTA OPTOMETRY AND OPHTHALMIC DISPENSING CARE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:DVORETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:212-923-2020
Mailing Address - Street 1:817 W 181ST ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-4516
Mailing Address - Country:US
Mailing Address - Phone:212-923-2020
Mailing Address - Fax:212-923-0260
Practice Address - Street 1:817 W 181ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-4516
Practice Address - Country:US
Practice Address - Phone:212-923-2020
Practice Address - Fax:212-923-0260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT006118152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5965450001Medicare NSC
NYCCWFX1Medicare PIN