Provider Demographics
NPI:1811948052
Name:LISITSYN, OLEG (OD)
Entity type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:LISITSYN
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 1:25 ROME AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4317
Mailing Address - Country:US
Mailing Address - Phone:718-442-1981
Mailing Address - Fax:718-265-9219
Practice Address - Street 1:731 LYDIG AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-2103
Practice Address - Country:US
Practice Address - Phone:718-829-2160
Practice Address - Fax:718-829-9502
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7894651OtherAETNA PPO
NY12291667Other12291667
NY9681151OtherGHI
NY02207129Medicaid
NY3693940OtherAETNA
NY52917OtherDAVIS VISION
NYP2806825OtherOXFORD
NY204824POtherHIP
NY2420108OtherUNITED HEATHCARE
NY4C8453OtherHEALTH NET
NY8127719OtherCIGNA
NYC172A1OtherBLUE CROSS/BLUE SHIELD
NY52917OtherDAVIS VISION
NY204824POtherHIP