Provider Demographics
NPI:1508042771
Name:JACK DUBIN
Entity Type:Organization
Organization Name:JACK DUBIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPPLIER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:212-308-3002
Mailing Address - Street 1:50 SUTTON PL S
Mailing Address - Street 2:SOUTH 17F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4167
Mailing Address - Country:US
Mailing Address - Phone:212-308-3002
Mailing Address - Fax:212-308-3002
Practice Address - Street 1:50 SUTTON PL S
Practice Address - Street 2:SOUTH 17F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4167
Practice Address - Country:US
Practice Address - Phone:212-308-3002
Practice Address - Fax:212-308-3002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT001763-1332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0703280001Medicare NSC