Provider Demographics
NPI:1285231514
Name:LIDELL, EMILY ROSE (OD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:LIDELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:33 MITCHELL AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-1642
Mailing Address - Country:US
Mailing Address - Phone:160-772-3758
Mailing Address - Fax:607-687-4226
Practice Address - Street 1:33 MITCHELL AVE STE 207
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1642
Practice Address - Country:US
Practice Address - Phone:160-772-3758
Practice Address - Fax:607-723-7586
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009257152W00000X
NY009257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist