Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 4846 | NY |
NPI | 1053403972 |
---|---|
Provider Name | Mr. Alfred Michael Russitano |
First Address | Canastota, NY 13032-1335 |
Second Address | Canastota, NY 13032-1335 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2006 |
Last Update Date | 18/03/2008 |