Provider Demographics
NPI:1275720781
Name:OLD SARATOGA OPTOMETRY & OPHTHALMIC DISPENSING, PLLC
Entity Type:Organization
Organization Name:OLD SARATOGA OPTOMETRY & OPHTHALMIC DISPENSING, PLLC
Other - Org Name:OLD SARATOGA EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:518-692-2040
Mailing Address - Street 1:31 FERRY ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SCHUYLERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12871-1225
Mailing Address - Country:US
Mailing Address - Phone:518-695-3040
Mailing Address - Fax:518-695-3150
Practice Address - Street 1:1224 STATE ROUTE 29
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:NY
Practice Address - Zip Code:12834-6120
Practice Address - Country:US
Practice Address - Phone:518-692-2040
Practice Address - Fax:518-692-2440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005918152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5391060001Medicare NSC
NY1275720781Medicare PIN
NYBA0479Medicare PIN