Provider Demographics
NPI:1619000353
Name:BRISLIN, JEROME EARL (OD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:EARL
Last Name:BRISLIN
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 1:577 DUTCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:PARISH
Mailing Address - State:NY
Mailing Address - Zip Code:13131-3167
Mailing Address - Country:US
Mailing Address - Phone:315-625-7533
Mailing Address - Fax:315-625-7533
Practice Address - Street 1:577 DUTCH HILL RD
Practice Address - Street 2:
Practice Address - City:PARISH
Practice Address - State:NY
Practice Address - Zip Code:13131-3167
Practice Address - Country:US
Practice Address - Phone:315-625-7533
Practice Address - Fax:315-625-7533
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist