Provider Demographics
NPI:1548746811
Name:PEARSON, BRYANT EDWARD (OPHTHALMIC DISPENSER)
Entity Type:Individual
Prefix:MR
First Name:BRYANT
Middle Name:EDWARD
Last Name:PEARSON
Suffix:
Gender:M
Credentials:OPHTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 BAY STREET
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304
Mailing Address - Country:US
Mailing Address - Phone:917-529-2251
Mailing Address - Fax:
Practice Address - Street 1:664 BAY STREET
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304
Practice Address - Country:US
Practice Address - Phone:917-529-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010122156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician