Provider Demographics
NPI:1053596734
Name:TISCH, ALLEN (MD)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:TISCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:CORNWALL ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12520-1806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:268 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:CORNWALL ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12520-1806
Practice Address - Country:US
Practice Address - Phone:845-534-2328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105400-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00519668Medicaid
NYAT0587201OtherMEDICARE
NYB16976Medicare UPIN