Provider Demographics
NPI:1063688547
Name:PROTOSOW, KRISTIN ANN (OPTOMETRIST, OD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANN
Last Name:PROTOSOW
Suffix:
Gender:F
Credentials:OPTOMETRIST, OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 HAWKINS AVE.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779
Mailing Address - Country:US
Mailing Address - Phone:631-588-5100
Mailing Address - Fax:631-588-5185
Practice Address - Street 1:624 HAWKINS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2375
Practice Address - Country:US
Practice Address - Phone:631-588-5100
Practice Address - Fax:631-588-5185
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007254-1152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation