Provider Demographics
NPI:1467598334
Name:AVERY, RUSSELL JOHN SR (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:JOHN
Last Name:AVERY
Suffix:SR
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-5715
Mailing Address - Country:US
Mailing Address - Phone:607-748-5463
Mailing Address - Fax:
Practice Address - Street 1:KNAUF OPTICAL
Practice Address - Street 2:235 VESTAL AVE.
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760
Practice Address - Country:US
Practice Address - Phone:607-748-0765
Practice Address - Fax:607-748-0765
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6965156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4853080001Medicare NSC