Provider Demographics
NPI:1407811300
Name:ROMAINE, EVAN DAVID (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:DAVID
Last Name:ROMAINE
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25115 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1708
Mailing Address - Country:US
Mailing Address - Phone:718-805-2020
Mailing Address - Fax:718-805-2020
Practice Address - Street 1:9008 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2103
Practice Address - Country:US
Practice Address - Phone:718-805-2020
Practice Address - Fax:718-805-2020
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005731-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01615012Medicaid
NY01615012Medicaid