Provider Demographics
NPI:1336492370
Name:BLAINE, VALENTINA (OD)
Entity Type:Individual
Prefix:MRS
First Name:VALENTINA
Middle Name:
Last Name:BLAINE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3535
Mailing Address - Country:US
Mailing Address - Phone:631-467-0524
Mailing Address - Fax:631-467-0530
Practice Address - Street 1:1958 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720
Practice Address - Country:US
Practice Address - Phone:631-467-0524
Practice Address - Fax:631-467-0530
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007930152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist