Provider Demographics
NPI:1174014591
Name:NY OPTOMETRIST VISION PC
Entity Type:Organization
Organization Name:NY OPTOMETRIST VISION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FUZAYLOV
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-591-3000
Mailing Address - Street 1:15036 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3928
Mailing Address - Country:US
Mailing Address - Phone:718-591-3000
Mailing Address - Fax:
Practice Address - Street 1:15036 UNION TPKE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3928
Practice Address - Country:US
Practice Address - Phone:718-591-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008487152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty