Provider Demographics
NPI:1023325107
Name:ELLISON, HOWARD RANDOLPH II (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:HOWARD
Middle Name:RANDOLPH
Last Name:ELLISON
Suffix:II
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 1:132 E FORDHAM RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-5408
Mailing Address - Country:US
Mailing Address - Phone:718-561-1600
Mailing Address - Fax:718-561-1611
Practice Address - Street 1:132 E FORDHAM RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-5408
Practice Address - Country:US
Practice Address - Phone:718-561-1600
Practice Address - Fax:718-561-1611
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008765156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician