Provider Demographics
NPI:1104002088
Name:PLAZA OPTICAL CENTRE, INC
Entity Type:Organization
Organization Name:PLAZA OPTICAL CENTRE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANCONA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-384-4700
Mailing Address - Street 1:225 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-5692
Mailing Address - Country:US
Mailing Address - Phone:718-384-4700
Mailing Address - Fax:718-387-3139
Practice Address - Street 1:225 S 4TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-5692
Practice Address - Country:US
Practice Address - Phone:718-384-4700
Practice Address - Fax:718-387-3139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005837332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0615000001Medicare NSC