Provider Demographics
NPI:1053403972
Name:RUSSITANO, ALFRED MICHAEL (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:MICHAEL
Last Name:RUSSITANO
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CANASTOTA
Mailing Address - State:NY
Mailing Address - Zip Code:13032-1335
Mailing Address - Country:US
Mailing Address - Phone:315-697-3334
Mailing Address - Fax:315-697-3423
Practice Address - Street 1:174 CANAL ST
Practice Address - Street 2:
Practice Address - City:CANASTOTA
Practice Address - State:NY
Practice Address - Zip Code:13032-1335
Practice Address - Country:US
Practice Address - Phone:315-697-3334
Practice Address - Fax:315-697-3423
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4846156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0551880001Medicare NSC