Provider Demographics
NPI:1679501001
Name:UTRECHT, ELLIOTT (OD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:UTRECHT
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 1:50 E VIEW CT
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753
Mailing Address - Country:US
Mailing Address - Phone:516-681-5868
Mailing Address - Fax:516-932-8688
Practice Address - Street 1:425 MADISON AVE
Practice Address - Street 2:STE 1501
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017
Practice Address - Country:US
Practice Address - Phone:212-753-1466
Practice Address - Fax:516-932-8688
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYT002165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00329355Medicaid
T81345Medicare UPIN
NYC28511Medicare ID - Type Unspecified