Provider Demographics
NPI:1487637500
Name:KINGSBRIDGE OPTOMETRIC EYE CARE P.C.
Entity Type:Organization
Organization Name:KINGSBRIDGE OPTOMETRIC EYE CARE P.C.
Other - Org Name:KINGSBRIDGE EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-432-5555
Mailing Address - Street 1:103 W KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3902
Mailing Address - Country:US
Mailing Address - Phone:718-432-5555
Mailing Address - Fax:
Practice Address - Street 1:103 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3902
Practice Address - Country:US
Practice Address - Phone:718-432-5555
Practice Address - Fax:718-548-2399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02632864Medicaid
NYA100034009Medicare PIN
NYC207F1Medicare ID - Type Unspecified
NY02632864Medicaid