Provider Demographics
NPI:1083647705
Name:BONAFIDE OPTICIANS OF AVE L INC
Entity Type:Organization
Organization Name:BONAFIDE OPTICIANS OF AVE L INC
Other - Org Name:BONAFIDE OPTICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:IQBAL
Authorized Official - Middle Name:
Authorized Official - Last Name:VENJARA
Authorized Official - Suffix:
Authorized Official - Credentials:OPHTHALMIC DISPENSER
Authorized Official - Phone:718-444-3126
Mailing Address - Street 1:9508 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4811
Mailing Address - Country:US
Mailing Address - Phone:718-444-3126
Mailing Address - Fax:718-444-3126
Practice Address - Street 1:9508 AVENUE L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4811
Practice Address - Country:US
Practice Address - Phone:718-444-3126
Practice Address - Fax:718-444-3126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005083-1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01501440Medicaid
NYA100076312Medicare PIN
NY01501440Medicaid