Provider Demographics
NPI:1639396856
Name:PROFESSIONAL OPTOMETRY DOWNTOWN, PC
Entity Type:Organization
Organization Name:PROFESSIONAL OPTOMETRY DOWNTOWN, 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:OPTOMETRIST
Authorized Official - Phone:518-463-1707
Mailing Address - Street 1:65 WOLF RD STE 106
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-2621
Mailing Address - Country:US
Mailing Address - Phone:518-463-1707
Mailing Address - Fax:518-949-2499
Practice Address - Street 1:65 WOLF RD STE 106
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-2621
Practice Address - Country:US
Practice Address - Phone:518-463-1707
Practice Address - Fax:518-949-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005329152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01734192Medicaid
1191170001OtherMEDICARE DME
NY000405842001OtherBLUE SHIELD
NY10020324OtherCDPHP
NYC2A901OtherEMPIRE BLUE CROSS BLUE SH
NY489OtherDAVIS VISION
NY59118OtherMVP
NY10020324OtherCDPHP
U38069Medicare UPIN
NY01734192Medicaid