Provider Demographics
NPI:1841380748
Name:ROSTKOWSKI, THERESA (OD, MSW, MA)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:ROSTKOWSKI
Suffix:
Gender:F
Credentials:OD, MSW, MA
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:ROSTKOWSKI
Other - Last Name:TANZIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD, MSW, MA
Mailing Address - Street 1:445 5TH AVE
Mailing Address - Street 2:APARTMENT 21B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-0133
Mailing Address - Country:US
Mailing Address - Phone:212-679-6647
Mailing Address - Fax:212-679-6647
Practice Address - Street 1:445 5TH AVE
Practice Address - Street 2:APARTMENT 21B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-0109
Practice Address - Country:US
Practice Address - Phone:212-679-6647
Practice Address - Fax:212-679-6647
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029620104100000X
NYTUV005138152W00000X
MA3610152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400007690Medicare PIN