Provider Demographics
NPI:1669441747
Name:BYWATER, MICHAEL THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:BYWATER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:216 ROUTE 299
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-7517
Mailing Address - Country:US
Mailing Address - Phone:845-691-8890
Mailing Address - Fax:845-834-3224
Practice Address - Street 1:216 ROUTE 299
Practice Address - Street 2:SUITE 4
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528-7517
Practice Address - Country:US
Practice Address - Phone:845-691-8890
Practice Address - Fax:845-834-3224
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV4980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02745788Medicaid
NY02745788Medicaid
NYU27400Medicare UPIN