Provider Demographics
NPI:1386819340
Name:SUTTON, ANDREA TRACY (OD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:TRACY
Last Name:SUTTON
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 1:4338 AMBOY RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-3820
Mailing Address - Country:US
Mailing Address - Phone:718-494-1319
Mailing Address - Fax:
Practice Address - Street 1:4338 AMBOY RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3820
Practice Address - Country:US
Practice Address - Phone:718-494-1319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT004800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100074672Medicare PIN