Provider Demographics
NPI:1518344365
Name:ABAZAGA, MIRJETA (OD)
Entity Type:Individual
Prefix:
First Name:MIRJETA
Middle Name:
Last Name:ABAZAGA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 HARRISON ST STE L
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3188
Mailing Address - Country:US
Mailing Address - Phone:315-464-5253
Mailing Address - Fax:315-464-6663
Practice Address - Street 1:550 HARRISON ST STE L
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3188
Practice Address - Country:US
Practice Address - Phone:315-464-5253
Practice Address - Fax:315-464-6663
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008346152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1518344365OtherNPI