Provider Demographics
NPI:1366654550
Name:THE EYEGLASS STORE
Entity Type:Organization
Organization Name:THE EYEGLASS STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:WASSERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-978-0800
Mailing Address - Street 1:1275 SUMMER STREET
Mailing Address - Street 2:STE 200
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905
Mailing Address - Country:US
Mailing Address - Phone:203-978-0800
Mailing Address - Fax:203-978-1284
Practice Address - Street 1:1275 SUMMER STREET
Practice Address - Street 2:STE 200
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905
Practice Address - Country:US
Practice Address - Phone:203-978-0800
Practice Address - Fax:203-978-1284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001622332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC23196Medicare UPIN