Provider Demographics
NPI:1093831497
Name:THE WANDERING EYE
Entity Type:Organization
Organization Name:THE WANDERING EYE
Other - Org Name:JEFF ROTH
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTICIAN OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:FNAO
Authorized Official - Phone:516-378-5183
Mailing Address - Street 1:526 NORTH 12TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4340
Mailing Address - Country:US
Mailing Address - Phone:516-318-5183
Mailing Address - Fax:
Practice Address - Street 1:526 NORTH 12TH ST
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4340
Practice Address - Country:US
Practice Address - Phone:516-318-5183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty