Provider Demographics
NPI:1982782835
Name:LOLIS, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LOLIS
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 1:5 RUSSELL PARK RD
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-5414
Mailing Address - Country:US
Mailing Address - Phone:516-822-7573
Mailing Address - Fax:
Practice Address - Street 1:185 W MERRICK RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3712
Practice Address - Country:US
Practice Address - Phone:516-867-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4726152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01246148Medicaid