Provider Demographics
NPI:1396832515
Name:OPTICAL WAREHOUSE OUTLET OF WILLIAMSBURG
Entity Type:Organization
Organization Name:OPTICAL WAREHOUSE OUTLET OF WILLIAMSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTSOWSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:917-674-1989
Mailing Address - Street 1:366 GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-2410
Mailing Address - Country:US
Mailing Address - Phone:718-388-3300
Mailing Address - Fax:718-388-3328
Practice Address - Street 1:366 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-2410
Practice Address - Country:US
Practice Address - Phone:718-388-3300
Practice Address - Fax:718-388-3328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT006545152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty