Provider Demographics
NPI:1407319155
Name:WATERTOWN MEDICAL OPTICAL PLLC
Entity Type:Organization
Organization Name:WATERTOWN MEDICAL OPTICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PRASHAW
Authorized Official - Suffix:
Authorized Official - Credentials:OPTHALMIC DISPENSER
Authorized Official - Phone:315-393-7171
Mailing Address - Street 1:77 W BARNEY ST STE F
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1040
Mailing Address - Country:US
Mailing Address - Phone:315-287-3638
Mailing Address - Fax:315-287-3656
Practice Address - Street 1:77 W BARNEY ST STE F
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1040
Practice Address - Country:US
Practice Address - Phone:315-287-3638
Practice Address - Fax:315-287-3656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies