Provider Demographics
NPI:1316439177
Name:CARUSO, MICHAEL JAMES (OD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:CARUSO
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 1:658 MALTA AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020
Mailing Address - Country:US
Mailing Address - Phone:518-580-0553
Mailing Address - Fax:518-580-0557
Practice Address - Street 1:658 MALTA AVE
Practice Address - Street 2:STE 101
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020
Practice Address - Country:US
Practice Address - Phone:518-580-0553
Practice Address - Fax:518-580-0557
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NYTUV008849152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03425445Medicaid