Provider Demographics
NPI:1154443158
Name:PORT JEFFERSON OPTICIANS INC
Entity Type:Organization
Organization Name:PORT JEFFERSON OPTICIANS INC
Other - Org Name:BROOKHAVEN OPTICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTROROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:631-331-0600
Mailing Address - Street 1:208 ROUTE 112 STE 2
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1013
Mailing Address - Country:US
Mailing Address - Phone:631-331-0600
Mailing Address - Fax:631-331-0809
Practice Address - Street 1:208 ROUTE 112 STE 2
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1013
Practice Address - Country:US
Practice Address - Phone:631-331-0600
Practice Address - Fax:631-331-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01934578Medicaid