Provider Demographics
NPI:1508130493
Name:SHANE GALAN OD PC
Entity Type:Organization
Organization Name:SHANE GALAN OD PC
Other - Org Name:DIAMOND VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-766-2423
Mailing Address - Street 1:84 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4106
Mailing Address - Country:US
Mailing Address - Phone:516-766-2423
Mailing Address - Fax:516-766-2432
Practice Address - Street 1:84 N PARK AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4106
Practice Address - Country:US
Practice Address - Phone:516-766-2423
Practice Address - Fax:516-766-2432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005774152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU80166Medicare UPIN