Provider Demographics
NPI:1992903322
Name:TISDALE, RALPH ROBERT (OPHTHALMIC DISPENSER)
Entity type:Individual
Prefix:MR
First Name:RALPH
Middle Name:ROBERT
Last Name:TISDALE
Suffix:
Gender:M
Credentials:OPHTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3844 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-2634
Mailing Address - Country:US
Mailing Address - Phone:516-781-4444
Mailing Address - Fax:516-781-4060
Practice Address - Street 1:3844 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-2634
Practice Address - Country:US
Practice Address - Phone:516-781-4444
Practice Address - Fax:516-781-4060
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC003643-1156FC0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4380200001Medicare PIN