Provider Demographics
NPI:1407227044
Name:NORTH COUNTRY OPHTHALMOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:NORTH COUNTRY OPHTHALMOLOGY ASSOCIATES PC
Other - Org Name:THE OPTICAL OUTLET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENYS
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-393-3937
Mailing Address - Street 1:3 LYON PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2590
Mailing Address - Country:US
Mailing Address - Phone:315-393-3937
Mailing Address - Fax:315-393-0591
Practice Address - Street 1:3 LYON PL
Practice Address - Street 2:SUITE 101
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2590
Practice Address - Country:US
Practice Address - Phone:315-393-3937
Practice Address - Fax:315-393-0591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC7949-1332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01880533Medicaid