Provider Demographics
NPI:1326165812
Name:SOOHOO, GANT GILBERT (OPTICAN)
Entity Type:Individual
Prefix:MR
First Name:GANT
Middle Name:GILBERT
Last Name:SOOHOO
Suffix:
Gender:M
Credentials:OPTICAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 PORTION RD STE 14
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4584
Mailing Address - Country:US
Mailing Address - Phone:631-648-9488
Mailing Address - Fax:631-648-9487
Practice Address - Street 1:601 PORTION RD STE 14
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4584
Practice Address - Country:US
Practice Address - Phone:631-648-9488
Practice Address - Fax:631-648-9487
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4191156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY541884840001Medicare ID - Type Unspecified
NY5418848400Medicare NSC