Provider Demographics
NPI:1275528358
Name:COSENZA, PAUL R (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:R
Last Name:COSENZA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 N WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-1635
Mailing Address - Country:US
Mailing Address - Phone:631-226-2020
Mailing Address - Fax:631-226-7371
Practice Address - Street 1:651 N WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1635
Practice Address - Country:US
Practice Address - Phone:631-226-2020
Practice Address - Fax:631-226-7371
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004106-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00880442Medicaid
NY0234820001Medicare NSC
NY00880442Medicaid
NYC3113CASF1Medicare PIN