Provider Demographics
NPI:1063660256
Name:JEROME E BRISLIN OD PC
Entity Type:Organization
Organization Name:JEROME E BRISLIN OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRISLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-625-7533
Mailing Address - Street 1:8251 NEW FLOYD RD
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-0553
Mailing Address - Country:US
Mailing Address - Phone:315-865-4299
Mailing Address - Fax:315-865-6359
Practice Address - Street 1:1294 UPPER LENOX AVE
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2681
Practice Address - Country:US
Practice Address - Phone:315-361-4050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA1153Medicare PIN