Provider Demographics
NPI:1275144057
Name:EMMETT, RALPH
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:EMMETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2337 31ST DR APT 4R
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4296
Mailing Address - Country:US
Mailing Address - Phone:570-430-5956
Mailing Address - Fax:
Practice Address - Street 1:127 SOUTH ST
Practice Address - Street 2:
Practice Address - City:OYSTER BAY
Practice Address - State:NY
Practice Address - Zip Code:11771-2226
Practice Address - Country:US
Practice Address - Phone:570-430-5956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009130152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist