Provider Demographics
NPI:1225238322
Name:BISSOON, NATALIE (OD)
Entity Type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:
Last Name:BISSOON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12015 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2117
Mailing Address - Country:US
Mailing Address - Phone:718-843-2156
Mailing Address - Fax:718-843-2691
Practice Address - Street 1:12015 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-2117
Practice Address - Country:US
Practice Address - Phone:718-843-2156
Practice Address - Fax:718-843-2691
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007180152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY08089IMedicare PIN