Provider Demographics
NPI:1245415595
Name:RUSSELL WOHL OD LLC
Entity Type:Organization
Organization Name:RUSSELL WOHL OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:WOHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-264-1515
Mailing Address - Street 1:85 BROADWAY
Mailing Address - Street 2:STE C
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2743
Mailing Address - Country:US
Mailing Address - Phone:631-264-1515
Mailing Address - Fax:631-264-2515
Practice Address - Street 1:85 BROADWAY
Practice Address - Street 2:STE C
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2743
Practice Address - Country:US
Practice Address - Phone:631-264-1515
Practice Address - Fax:631-264-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100030762Medicare PIN
NY0517050001Medicare NSC