Provider Demographics
NPI:1043496367
Name:FRESH EYES INC
Entity Type:Organization
Organization Name:FRESH EYES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEGELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-454-8484
Mailing Address - Street 1:6130A 190TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2721
Mailing Address - Country:US
Mailing Address - Phone:718-454-8484
Mailing Address - Fax:718-454-8910
Practice Address - Street 1:6130A 190TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2721
Practice Address - Country:US
Practice Address - Phone:718-454-8484
Practice Address - Fax:718-454-8910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV43351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0610950001Medicare NSC