Provider Demographics
NPI:1275989782
Name:BISMUTH, JOSH
Entity Type:Individual
Prefix:
First Name:JOSH
Middle Name:
Last Name:BISMUTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25-01 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106
Mailing Address - Country:US
Mailing Address - Phone:347-254-1625
Mailing Address - Fax:718-721-1220
Practice Address - Street 1:25-01 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106
Practice Address - Country:US
Practice Address - Phone:347-254-1625
Practice Address - Fax:718-721-1220
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY92888900156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician