Provider Demographics
NPI:1467577007
Name:PORETSKY, SCOTT R
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:R
Last Name:PORETSKY
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 1:233 UNION AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1820
Mailing Address - Country:US
Mailing Address - Phone:631-580-2020
Mailing Address - Fax:
Practice Address - Street 1:233 UNION AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1820
Practice Address - Country:US
Practice Address - Phone:631-580-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007083156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6163420001Medicare NSC