Provider Demographics
NPI:1629232632
Name:MEZGER, WARREN T (OD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:T
Last Name:MEZGER
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 1:4 FULLER ST
Mailing Address - Street 2:RIVER HOSPITAL
Mailing Address - City:ALEXANDRIA BAY
Mailing Address - State:NY
Mailing Address - Zip Code:13607-1316
Mailing Address - Country:US
Mailing Address - Phone:941-661-2694
Mailing Address - Fax:
Practice Address - Street 1:4 FULLER ST
Practice Address - Street 2:RIVER HOSPITAL
Practice Address - City:ALEXANDRIA BAY
Practice Address - State:NY
Practice Address - Zip Code:13607-1316
Practice Address - Country:US
Practice Address - Phone:941-661-2694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002772-1152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16618799ME1Medicare PIN