Provider Demographics
NPI:1720255060
Name:THEODORE N ISSEKS MD PC
Entity Type:Organization
Organization Name:THEODORE N ISSEKS MD PC
Other - Org Name:FAMILY OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:ISSEKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-292-1111
Mailing Address - Street 1:5518 STATE ROUTE 55
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754
Mailing Address - Country:US
Mailing Address - Phone:845-292-1111
Mailing Address - Fax:845-292-1821
Practice Address - Street 1:5518 STATE ROUTE 55
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754
Practice Address - Country:US
Practice Address - Phone:845-292-1111
Practice Address - Fax:845-292-1821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THEODORE N ISSEKS MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-15
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117110207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0913200001Medicare NSC
NYB12758Medicare UPIN