Provider Demographics
NPI:1033535653
Name:MA, KALEENA
Entity Type:Individual
Prefix:
First Name:KALEENA
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10729 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10729 71ST AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4724
Practice Address - Country:US
Practice Address - Phone:718-575-8288
Practice Address - Fax:718-575-8110
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03279398Medicaid