Provider Demographics
NPI:1295412526
Name:VISSICCHIO, CHRISTOPHER JOHN (OD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:VISSICCHIO
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 1:2706 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4624
Mailing Address - Country:US
Mailing Address - Phone:516-732-7589
Mailing Address - Fax:
Practice Address - Street 1:313 MERRICK RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5325
Practice Address - Country:US
Practice Address - Phone:516-536-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009775-01152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist