Provider Demographics
NPI:1346316718
Name:TISCH, CRAIG BRIAN (OD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:BRIAN
Last Name:TISCH
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 1:244 WEST 54TH STREET
Mailing Address - Street 2:SUITE 402
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019
Mailing Address - Country:US
Mailing Address - Phone:212-765-2660
Mailing Address - Fax:212-765-2714
Practice Address - Street 1:244 WEST 54TH STREET
Practice Address - Street 2:SUITE 402
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-765-2660
Practice Address - Fax:212-765-2714
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005672-1152W00000X
NY005672152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01618693Medicaid
NYC03651OtherPTAN
NY01777128Medicaid
NY01777128Medicaid
NYC5W961Medicare ID - Type UnspecifiedGRP NUMBER