Provider Demographics
NPI:1558438820
Name:DIVIETRO, MARK ANDREW (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:DIVIETRO
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Gender:M
Credentials:OPTICIAN
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Mailing Address - Street 1:97 GENESEE STREET
Mailing Address - Street 2:SILBERT OPTICAL INC
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-3683
Mailing Address - Country:US
Mailing Address - Phone:315-253-7032
Mailing Address - Fax:315-252-6377
Practice Address - Street 1:97 GENESEE STREET
Practice Address - Street 2:SILBERT OPTICAL INC
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-3683
Practice Address - Country:US
Practice Address - Phone:315-253-7032
Practice Address - Fax:315-252-6377
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
NYC0067671156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician