Provider Demographics
NPI:1588784094
Name:SCHLACTUS, BARRY (OD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:
Last Name:SCHLACTUS
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 1:124 SMITH HAVEN MALL
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1214
Mailing Address - Country:US
Mailing Address - Phone:631-724-9055
Mailing Address - Fax:631-724-9142
Practice Address - Street 1:124 SMITH HAVEN MALL
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1214
Practice Address - Country:US
Practice Address - Phone:631-724-9055
Practice Address - Fax:631-724-9142
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003919-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2567013Medicaid