Provider Demographics
NPI:1407995863
Name:PREMIUM LASER OPHTHALMOLOGY LLC
Entity Type:Organization
Organization Name:PREMIUM LASER OPHTHALMOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:HORNFELD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:212-590-8881
Mailing Address - Street 1:125 WEST 79TH STREET
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024
Mailing Address - Country:US
Mailing Address - Phone:212-580-8881
Mailing Address - Fax:
Practice Address - Street 1:125 W 79TH ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6454
Practice Address - Country:US
Practice Address - Phone:212-580-8881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179425207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWET281Medicare ID - Type Unspecified