Provider Demographics
NPI:1275648636
Name:FAZIO, IRINA KOTOVSKY (OD)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:KOTOVSKY
Last Name:FAZIO
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 1:3215 41ST ST APT D3
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3537
Mailing Address - Country:US
Mailing Address - Phone:646-483-9165
Mailing Address - Fax:
Practice Address - Street 1:1042 SECOND AVE
Practice Address - Street 2:LENSCRAFTERS INC,
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:212-759-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007075152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist