Provider Demographics
NPI:1376642975
Name:MAK OPTICAL OF NEW YORK INC
Entity Type:Organization
Organization Name:MAK OPTICAL OF NEW YORK INC
Other - Org Name:PEARLE VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-459-7100
Mailing Address - Street 1:6135 JUNCTION BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2771
Mailing Address - Country:US
Mailing Address - Phone:718-459-7100
Mailing Address - Fax:
Practice Address - Street 1:6135 JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2771
Practice Address - Country:US
Practice Address - Phone:718-459-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY7701156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01421416Medicaid
NY0841860001Medicare NSC
NY01421416Medicaid