Provider Demographics
NPI:1255594453
Name:TISDALE, SCOTT TASHIRO (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:TASHIRO
Last Name:TISDALE
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 1:155E 38TH ST 6L
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-2675
Mailing Address - Country:US
Mailing Address - Phone:516-457-0757
Mailing Address - Fax:
Practice Address - Street 1:8565 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1804
Practice Address - Country:US
Practice Address - Phone:516-367-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007268152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist