Provider Demographics
NPI:1629208525
Name:BEDOY, LACEY DUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:LACEY
Middle Name:DUSTIN
Last Name:BEDOY
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 1:454 MALCOLM X BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-3320
Mailing Address - Country:US
Mailing Address - Phone:212-368-2020
Mailing Address - Fax:201-797-5809
Practice Address - Street 1:454 MALCOLM X BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-3320
Practice Address - Country:US
Practice Address - Phone:212-368-2020
Practice Address - Fax:201-797-5809
Is Sole Proprietor?:No
Enumeration Date:2009-07-26
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007642-1152W00000X
NJ27OAOO620000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400062711Medicare PIN