Provider Demographics
NPI:1669143079
Name:MUTTREJA, TIMSI (OD)
Entity type:Individual
Prefix:DR
First Name:TIMSI
Middle Name:
Last Name:MUTTREJA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7108
Mailing Address - Country:US
Mailing Address - Phone:631-871-5220
Mailing Address - Fax:
Practice Address - Street 1:233 SPRING ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-1522
Practice Address - Country:US
Practice Address - Phone:888-492-7297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist