Provider Demographics
NPI:1437383635
Name:TONGSRI, EKSUPAR (OD)
Entity Type:Individual
Prefix:
First Name:EKSUPAR
Middle Name:
Last Name:TONGSRI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1594 FLATBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-3030
Mailing Address - Country:US
Mailing Address - Phone:917-664-4446
Mailing Address - Fax:
Practice Address - Street 1:415 GRAND STREET
Practice Address - Street 2:E1505
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002
Practice Address - Country:US
Practice Address - Phone:917-664-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006827-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA4000017296Medicare PIN