Provider Demographics
NPI:1194226886
Name:ESAD OPTICAL, INC
Entity Type:Organization
Organization Name:ESAD OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:F
Authorized Official - Last Name:DE JUNCO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-641-1768
Mailing Address - Street 1:708 SEABURY AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-4112
Mailing Address - Country:US
Mailing Address - Phone:516-641-1768
Mailing Address - Fax:
Practice Address - Street 1:6332 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:EAST NORWICH
Practice Address - State:NY
Practice Address - Zip Code:11732-1600
Practice Address - Country:US
Practice Address - Phone:516-624-3149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004987152W00000X, 152WC0802X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03239461Medicaid