Provider Demographics
NPI:1346638434
Name:ISLAND EYE OPTICAL CORP.
Entity Type:Organization
Organization Name:ISLAND EYE OPTICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NEJAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-984-7616
Mailing Address - Street 1:4299 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-6527
Mailing Address - Country:US
Mailing Address - Phone:718-984-7616
Mailing Address - Fax:718-984-8584
Practice Address - Street 1:1500 VICTORY BOULEVARD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301
Practice Address - Country:US
Practice Address - Phone:718-984-7616
Practice Address - Fax:718-984-8584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-26
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0017979-1152W00000X
NY004733-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty