Provider Demographics
NPI:1134517584
Name:BAZAN OPTOMETRIC SERVICES LLC
Entity Type:Organization
Organization Name:BAZAN OPTOMETRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:646-496-7365
Mailing Address - Street 1:682 UNION ST
Mailing Address - Street 2:PARK SLOPE EYE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-2047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 HUTCHINSON RIVER PKWY
Practice Address - Street 2:INSIDE TARGET OPTICAL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-1887
Practice Address - Country:US
Practice Address - Phone:718-822-2305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006867152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty