Provider Demographics
NPI:1558346684
Name:WOHL, RUSSELL MARK (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:MARK
Last Name:WOHL
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 1:255 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2619
Mailing Address - Country:US
Mailing Address - Phone:516-249-0052
Mailing Address - Fax:516-249-7000
Practice Address - Street 1:255 MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2619
Practice Address - Country:US
Practice Address - Phone:516-249-0052
Practice Address - Fax:516-249-7000
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0043431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01524496Medicaid
T49030Medicare UPIN
NY01524496Medicaid
C32092Medicare PIN