Provider Demographics
NPI:1053728675
Name:NORTH COUNTRY OPTICAL
Entity type:Organization
Organization Name:NORTH COUNTRY OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITSOGLOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-563-7400
Mailing Address - Street 1:292 CORNELIA ST
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2303
Mailing Address - Country:US
Mailing Address - Phone:518-563-7400
Mailing Address - Fax:
Practice Address - Street 1:292 CORNELIA ST
Practice Address - Street 2:BUILDING 2
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2303
Practice Address - Country:US
Practice Address - Phone:518-563-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005623152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty