Provider Demographics
NPI:1336711373
Name:STYCZYNSKI, MITCHELL JAY (OD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JAY
Last Name:STYCZYNSKI
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 1:45 LYME RD
Mailing Address - Street 2:STE 201
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-1260
Mailing Address - Country:US
Mailing Address - Phone:603-643-2140
Mailing Address - Fax:
Practice Address - Street 1:45 LYME RD STE 201
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-1260
Practice Address - Country:US
Practice Address - Phone:603-643-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-10
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0133942152W00000X
NH1059152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist