Provider Demographics
NPI:1619190493
Name:BUTENKO, OLESSIA XENIA (OD)
Entity Type:Individual
Prefix:
First Name:OLESSIA
Middle Name:XENIA
Last Name:BUTENKO
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 1:131 TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-1420
Mailing Address - Country:US
Mailing Address - Phone:607-760-9275
Mailing Address - Fax:
Practice Address - Street 1:3018 EAST AVE
Practice Address - Street 2:INSIDE WALMART VISION CENTER
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-2713
Practice Address - Country:US
Practice Address - Phone:315-668-0422
Practice Address - Fax:315-668-0424
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000125424OtherBCBS
NY366116OtherMVP
NY27761OtherSUPERIOR