Provider Demographics
NPI:1124030960
Name:FLUSHING MALL OPTICAL, INC.
Entity Type:Organization
Organization Name:FLUSHING MALL OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MING
Authorized Official - Middle Name:KI
Authorized Official - Last Name:YUE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-888-2691
Mailing Address - Street 1:13333 39TH AVE
Mailing Address - Street 2:F22 FLUSHING MALL
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4432
Mailing Address - Country:US
Mailing Address - Phone:718-888-2691
Mailing Address - Fax:718-888-2691
Practice Address - Street 1:13333 39TH AVE
Practice Address - Street 2:F22 FLUSHING MALL
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4432
Practice Address - Country:US
Practice Address - Phone:718-888-2691
Practice Address - Fax:718-888-2691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005285156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02253249Medicaid
NY5311770001Medicare NSC