Provider Demographics
NPI:1356677876
Name:WOODSIDE OPTOMETRY PC
Entity Type:Organization
Organization Name:WOODSIDE OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PUNEET
Authorized Official - Middle Name:
Authorized Official - Last Name:RASTOGI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:312-925-9519
Mailing Address - Street 1:4811 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4450
Mailing Address - Country:US
Mailing Address - Phone:718-205-9760
Mailing Address - Fax:
Practice Address - Street 1:4811 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11377-4450
Practice Address - Country:US
Practice Address - Phone:718-205-9760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty