Provider Demographics
NPI:1497364095
Name:AMINOVA, GABRIELLE (OD)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:AMINOVA
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 1:69 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-7503
Mailing Address - Country:US
Mailing Address - Phone:718-522-3332
Mailing Address - Fax:
Practice Address - Street 1:69 LEE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-7503
Practice Address - Country:US
Practice Address - Phone:718-522-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009211152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist