Provider Demographics
NPI:1326092982
Name:NEJATHEIM, ALLON (OD)
Entity Type:Individual
Prefix:
First Name:ALLON
Middle Name:
Last Name:NEJATHEIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248-12 NORTHERN BLVD
Mailing Address - Street 2:1D
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1207
Mailing Address - Country:US
Mailing Address - Phone:718-229-6780
Mailing Address - Fax:
Practice Address - Street 1:248-12 NORTHERN BLVD
Practice Address - Street 2:1D
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1207
Practice Address - Country:US
Practice Address - Phone:718-229-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006665152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU98621Medicare UPIN
07062GMedicare PIN
NY5572020001Medicare NSC