Provider Demographics
NPI:1184790420
Name:BISMUTH, GUY (OD)
Entity type:Individual
Prefix:DR
First Name:GUY
Middle Name:
Last Name:BISMUTH
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 1:267 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-2501
Mailing Address - Country:US
Mailing Address - Phone:914-395-1757
Mailing Address - Fax:914-395-1757
Practice Address - Street 1:267 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-2501
Practice Address - Country:US
Practice Address - Phone:914-395-1757
Practice Address - Fax:914-395-1757
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003417-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00329433Medicaid
NYT32171Medicare UPIN
NYC309F1Medicare ID - Type Unspecified