Provider Demographics
NPI:1346570256
Name:TERESA BLACKSTONE OD PC
Entity type:Organization
Organization Name:TERESA BLACKSTONE OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACKSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:518-580-9893
Mailing Address - Street 1:414 MAPLE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-5533
Mailing Address - Country:US
Mailing Address - Phone:518-597-0772
Mailing Address - Fax:518-587-8749
Practice Address - Street 1:414 MAPLE AVE STE 200
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-5533
Practice Address - Country:US
Practice Address - Phone:518-597-0772
Practice Address - Fax:518-587-8749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT004647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01419649Medicaid
NY01419649Medicaid
U17109Medicare UPIN