Provider Demographics
NPI:1356633937
Name:CRYSTAL OPTOMETRIC EYECARE, P.C.
Entity Type:Organization
Organization Name:CRYSTAL OPTOMETRIC EYECARE, P.C.
Other - Org Name:CROWN EYECARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-595-2266
Mailing Address - Street 1:18015 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2101
Mailing Address - Country:US
Mailing Address - Phone:718-595-2266
Mailing Address - Fax:718-595-2292
Practice Address - Street 1:300 ROUTE 18
Practice Address - Street 2:MIDSTATE MALL, SUITE#32B
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-1912
Practice Address - Country:US
Practice Address - Phone:732-651-8188
Practice Address - Fax:732-651-8199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00582400152WC0802X
NJ27OA00612000152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU99162Medicare UPIN