Provider Demographics
NPI:1427048347
Name:KOSIK, STACY M (OD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:M
Last Name:KOSIK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085D NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576
Mailing Address - Country:US
Mailing Address - Phone:576-365-4066
Mailing Address - Fax:516-365-9312
Practice Address - Street 1:KLM OPTICAL. INC. DBA PEARLE VISION
Practice Address - Street 2:1085 D NORTHERN BLVD
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576
Practice Address - Country:US
Practice Address - Phone:516-365-4066
Practice Address - Fax:516-365-9312
Is Sole Proprietor?:No
Enumeration Date:2005-10-22
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005889-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU75066Medicare UPIN
NYC57281Medicare ID - Type UnspecifiedPROVIDER NUMBER