Provider Demographics
NPI:1821118324
Name:VIZZI, TINA SUE (OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:SUE
Last Name:VIZZI
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:BARRY
Other - Last Name:KOMM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OPTICIAN
Mailing Address - Street 1:900 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-1737
Mailing Address - Country:US
Mailing Address - Phone:716-754-2555
Mailing Address - Fax:716-754-8650
Practice Address - Street 1:900 CENTER ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1737
Practice Address - Country:US
Practice Address - Phone:716-754-2555
Practice Address - Fax:716-754-8650
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC006277-01156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0509630001Medicare ID - Type Unspecified