Provider Demographics
NPI:1487625760
Name:MISHAN, MARC (OD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:MISHAN
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 1:8227 153RD AVE
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-1751
Mailing Address - Country:US
Mailing Address - Phone:718-738-3700
Mailing Address - Fax:718-738-3700
Practice Address - Street 1:8227 153RD AVE
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-1751
Practice Address - Country:US
Practice Address - Phone:718-738-3700
Practice Address - Fax:718-738-3700
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004164-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY31729GMedicare ID - Type Unspecified
NYT92364Medicare UPIN