Provider Demographics
NPI:1467629899
Name:PIZZO, BEVIN SHANNON (OPTICAN)
Entity Type:Individual
Prefix:
First Name:BEVIN
Middle Name:SHANNON
Last Name:PIZZO
Suffix:
Gender:F
Credentials:OPTICAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 ROUTE 300
Mailing Address - Street 2:SUITE 1054
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-2990
Mailing Address - Country:US
Mailing Address - Phone:845-566-9179
Mailing Address - Fax:
Practice Address - Street 1:1401 ROUTE 300
Practice Address - Street 2:SUITE 1054
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-2990
Practice Address - Country:US
Practice Address - Phone:845-566-9179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004141-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician