Provider Demographics
NPI:1043326424
Name:STOCKWIN, TAMARA (OD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:STOCKWIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRENTWOOD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1865
Mailing Address - Country:US
Mailing Address - Phone:607-257-5599
Mailing Address - Fax:607-257-3972
Practice Address - Street 1:10 BRENTWOOD DR
Practice Address - Street 2:SUITE A
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1865
Practice Address - Country:US
Practice Address - Phone:607-257-5599
Practice Address - Fax:607-257-3972
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0059541152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02566012Medicaid
NYU81915Medicare UPIN
NY02566012Medicaid