Provider Demographics
NPI:1629297759
Name:DR ELISA PERREAULT OPTOMETRIST PC
Entity Type:Organization
Organization Name:DR ELISA PERREAULT OPTOMETRIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERREAULT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:518-785-1199
Mailing Address - Street 1:952 TROY SCHENECTADY RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1608
Mailing Address - Country:US
Mailing Address - Phone:518-785-1199
Mailing Address - Fax:518-785-1199
Practice Address - Street 1:952 TROY SCHENECTADY RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1608
Practice Address - Country:US
Practice Address - Phone:518-785-1199
Practice Address - Fax:518-785-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT-005329152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4125247OtherMVP
NY10020324OtherCDPHP