Provider Demographics
NPI:1336321728
Name:CORONA OPTOMETRY, PC
Entity Type:Organization
Organization Name:CORONA OPTOMETRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PEZHMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOURIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-242-1333
Mailing Address - Street 1:103-06 ROOSEVELT AVENUE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:718-424-1333
Mailing Address - Fax:718-424-1330
Practice Address - Street 1:103-06 ROOSEVELT AVENUE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-424-1333
Practice Address - Fax:718-424-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02811172Medicaid
NY6305490001Medicare NSC
NYDP2386Medicare PIN
NY08309Medicare PIN