Provider Demographics
NPI:1093939001
Name:BROOK PLAZA OPTHALMOLOGY ASSOC PC
Entity Type:Organization
Organization Name:BROOK PLAZA OPTHALMOLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ACKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-629-5590
Mailing Address - Street 1:1901 UTICA AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3225
Mailing Address - Country:US
Mailing Address - Phone:718-968-8700
Mailing Address - Fax:718-968-8743
Practice Address - Street 1:1901 UTICA AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-3225
Practice Address - Country:US
Practice Address - Phone:718-968-8700
Practice Address - Fax:718-968-8743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02079207Medicaid
NY02079207Medicaid