Provider Demographics
NPI:1225203649
Name:STARLIGHT OPTICAL, INC
Entity Type:Organization
Organization Name:STARLIGHT OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STANISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:ILYUSHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-787-4111
Mailing Address - Street 1:1501 GRAVESEND NECK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4434
Mailing Address - Country:US
Mailing Address - Phone:718-787-4111
Mailing Address - Fax:718-787-4114
Practice Address - Street 1:1501 GRAVESEND NECK RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4434
Practice Address - Country:US
Practice Address - Phone:718-787-4111
Practice Address - Fax:718-787-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-26
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006443152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02218697Medicaid
NY02218697Medicaid
NYC191E2Medicare PIN
NYU89143Medicare UPIN