Provider Demographics
NPI:1962619916
Name:PHILLIPS, ROBERT E (ABOC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:E
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 CORNELIA ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2318
Mailing Address - Country:US
Mailing Address - Phone:518-561-8820
Mailing Address - Fax:518-561-2164
Practice Address - Street 1:210 CORNELIA ST
Practice Address - Street 2:SUITE 302
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2318
Practice Address - Country:US
Practice Address - Phone:518-561-8820
Practice Address - Fax:518-561-2164
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006405156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY26671OtherABO CERTIFICATION
NY006405OtherOPTICIAN LICENSE
NY02868142Medicaid