Provider Demographics
NPI:1114244563
Name:BRONX VISTASITE EYECARE INC
Entity Type:Organization
Organization Name:BRONX VISTASITE EYECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:LISITYSN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-324-2020
Mailing Address - Street 1:2100 BARTON AVE # 204
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475
Mailing Address - Country:US
Mailing Address - Phone:917-699-5876
Mailing Address - Fax:
Practice Address - Street 1:2204 BARTOW AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4616
Practice Address - Country:US
Practice Address - Phone:718-324-2020
Practice Address - Fax:347-843-0443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03010524Medicaid