| Doctor Name: | MR. EDWARD J MAMELOK |
| NPI Number: | 1588702559 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LO |
| License Number: | 001192 |
| Business Practice Address: | 15 Arcadia Road Old Greenwich, CT - 06870 |
| Business Phone Number: | 2036982255 |
| Business Fax Number: | 2036982655 |
| Mailing Address: | 15 Arcadia Road, OLD GREENWICH |
| State: | CT |
| Postal Code: | 06870 |
| Phone Number: | 2036982255 |
| Fax Number: | 2036982655 |
| NPI Enumeration Date: | 02/02/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | 001192 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CT |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |