Provider Demographics
NPI:1235328493
Name:LASER EYE PRACTICE OF BROOKLYN, PLLC
Entity Type:Organization
Organization Name:LASER EYE PRACTICE OF BROOKLYN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:DELLO RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-384-7333
Mailing Address - Street 1:1 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-2125
Mailing Address - Country:US
Mailing Address - Phone:201-384-7333
Mailing Address - Fax:201-384-9915
Practice Address - Street 1:100 LIVINGSTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5023
Practice Address - Country:US
Practice Address - Phone:718-254-9263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty