Provider Demographics
NPI:1689701005
Name:DULAK, MICHAEL THOMAS (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:DULAK
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 SAWGRASS CT
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075
Mailing Address - Country:US
Mailing Address - Phone:716-649-0436
Mailing Address - Fax:
Practice Address - Street 1:3876 SOUTH PARK AVE
Practice Address - Street 2:
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219
Practice Address - Country:US
Practice Address - Phone:716-822-2264
Practice Address - Fax:716-826-3068
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3845156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00917226Medicaid
NY0212580002Medicare ID - Type Unspecified