Provider Demographics
NPI:1851478259
Name:MODESTO, ANTHONY (OD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:MODESTO
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 1:385 ROUTE 25A
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2525
Mailing Address - Country:US
Mailing Address - Phone:631-642-8400
Mailing Address - Fax:631-642-8403
Practice Address - Street 1:385 ROUTE 25A
Practice Address - Street 2:SUITE 6
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2525
Practice Address - Country:US
Practice Address - Phone:631-642-8400
Practice Address - Fax:631-642-8403
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV00395-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00654848Medicaid
NYT78494Medicare UPIN
NYC29171Medicare ID - Type Unspecified