Provider Demographics
NPI:1205018488
Name:DYATLOV, ALLA (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:DYATLOV
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 FLATBUSH AVE
Mailing Address - Street 2:ATLANTIC TERMINAL MALL
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1450
Mailing Address - Country:US
Mailing Address - Phone:718-522-3737
Mailing Address - Fax:718-522-3894
Practice Address - Street 1:139 FLATBUSH AVE
Practice Address - Street 2:ATLANTIC TERMINAL MALL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1450
Practice Address - Country:US
Practice Address - Phone:718-522-3737
Practice Address - Fax:718-522-3894
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006774-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician