Provider Demographics
NPI:1093884496
Name:PODBERESKY, LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:
Last Name:PODBERESKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-1114
Mailing Address - Country:US
Mailing Address - Phone:845-782-1837
Mailing Address - Fax:845-774-8849
Practice Address - Street 1:358 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-1114
Practice Address - Country:US
Practice Address - Phone:845-782-1837
Practice Address - Fax:845-774-8849
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT004929-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01691625Medicaid
NYU56055Medicare UPIN
NY01691625Medicaid