Provider Demographics
NPI:1043501927
Name:MALOCO, ROMEO VELASCO JR (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:ROMEO
Middle Name:VELASCO
Last Name:MALOCO
Suffix:JR
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 1:524 JEFFERSON PLZ
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1104
Mailing Address - Country:US
Mailing Address - Phone:631-476-4707
Mailing Address - Fax:
Practice Address - Street 1:524 JEFFERSON PLZ
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1104
Practice Address - Country:US
Practice Address - Phone:631-476-4707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC006424-1156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter