Provider Demographics
NPI:1962632661
Name:STAMFORD OPHTHALMOLOGY, LLC
Entity Type:Organization
Organization Name:STAMFORD OPHTHALMOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDERIDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-327-5808
Mailing Address - Street 1:1351 WASHINGTON BLVD 101
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902
Mailing Address - Country:US
Mailing Address - Phone:203-327-5808
Mailing Address - Fax:203-352-5199
Practice Address - Street 1:1351 WASHINGTON BLVD 101
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902
Practice Address - Country:US
Practice Address - Phone:203-327-5808
Practice Address - Fax:203-352-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001612156FX1800X
CT030718207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01512Medicare UPIN
66991Medicare PIN