Provider Demographics
NPI:1093770463
Name:EVAN DAVID OPTICIANS
Entity Type:Organization
Organization Name:EVAN DAVID OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAINE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:718-805-2020
Mailing Address - Street 1:9008 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-2103
Mailing Address - Country:US
Mailing Address - Phone:718-805-2020
Mailing Address - Fax:718-805-2020
Practice Address - Street 1:9008 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2103
Practice Address - Country:US
Practice Address - Phone:718-805-2020
Practice Address - Fax:718-805-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01615012Medicaid
NY01615012Medicaid