Provider Demographics
NPI:1639246879
Name:DUL, MITCHELL WALTER (OD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:WALTER
Last Name:DUL
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 1:283 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NELSONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10516-1406
Mailing Address - Country:US
Mailing Address - Phone:845-265-4048
Mailing Address - Fax:
Practice Address - Street 1:33 W 42ND ST
Practice Address - Street 2:COLLEGE OF OPTOMETRY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-8005
Practice Address - Country:US
Practice Address - Phone:212-938-5818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004570-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00744394Medicaid
T81529Medicare UPIN
NY00744394Medicaid