Provider Demographics
NPI:1467715839
Name:POLISHCHUK, ROMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:POLISHCHUK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 49TH ST
Mailing Address - Street 2:MEDICAL & SURGICAL EYESITE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2922
Mailing Address - Country:US
Mailing Address - Phone:718-283-8000
Mailing Address - Fax:718-365-3655
Practice Address - Street 1:904 49TH ST
Practice Address - Street 2:MEDICAL & SURGICAL EYESITE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2922
Practice Address - Country:US
Practice Address - Phone:718-283-8000
Practice Address - Fax:718-365-3655
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007870152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist