Provider Demographics
NPI:1750573093
Name:DR.ANTHONY MODESTO OD PC
Entity type:Organization
Organization Name:DR.ANTHONY MODESTO OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MODESTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:631-642-8400
Mailing Address - Street 1:385 ROUTE 25A UNIT 6
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2501
Mailing Address - Country:US
Mailing Address - Phone:631-642-8400
Mailing Address - Fax:631-642-8403
Practice Address - Street 1:385 ROUTE 25A UNIT 6
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2501
Practice Address - Country:US
Practice Address - Phone:631-642-8400
Practice Address - Fax:631-642-8403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT003195152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEP071Medicare PIN
NYT78494Medicare UPIN
NY5676700001Medicare NSC