Provider Demographics
NPI:1083808778
Name:BERRIOS, MANUEL (NYS LIC 007961-1)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:BERRIOS
Suffix:
Gender:M
Credentials:NYS LIC 007961-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-7805
Mailing Address - Country:US
Mailing Address - Phone:347-270-4553
Mailing Address - Fax:347-271-5800
Practice Address - Street 1:4555 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-7805
Practice Address - Country:US
Practice Address - Phone:347-270-4553
Practice Address - Fax:347-271-5800
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007961-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician