Provider Demographics
NPI:1417092313
Name:MY OPTICIAN NYC CORP
Entity Type:Organization
Organization Name:MY OPTICIAN NYC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHLIMOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-693-1111
Mailing Address - Street 1:5227 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463
Mailing Address - Country:US
Mailing Address - Phone:212-693-1111
Mailing Address - Fax:212-693-1114
Practice Address - Street 1:5227 BROADWAY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-7636
Practice Address - Country:US
Practice Address - Phone:212-693-1111
Practice Address - Fax:212-693-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007320156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02622966Medicaid
NY02622966Medicaid