Provider Demographics
NPI:1417983446
Name:MUSIAL, MARK G (OPTHALMIC DISPENSER)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:G
Last Name:MUSIAL
Suffix:
Gender:M
Credentials:OPTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:260 BEACH 136TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLE HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1324
Mailing Address - Country:US
Mailing Address - Phone:718-945-0892
Mailing Address - Fax:718-634-2540
Practice Address - Street 1:6928 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7263
Practice Address - Country:US
Practice Address - Phone:718-381-4577
Practice Address - Fax:718-634-2540
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006109-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01612817Medicaid
NY06542Medicare ID - Type UnspecifiedGHI MEDICARE - QUEENS