Provider Demographics
NPI:1518117274
Name:OPTICALLY YOURS
Entity Type:Organization
Organization Name:OPTICALLY YOURS
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DIPERSIO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-745-3433
Mailing Address - Street 1:9215 THIRD AVE
Mailing Address - Street 2:OPTICALLY YOURS
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-6819
Mailing Address - Country:US
Mailing Address - Phone:718-745-3433
Mailing Address - Fax:
Practice Address - Street 1:9215 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-6819
Practice Address - Country:US
Practice Address - Phone:718-745-3433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00-4623-1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1125490001Medicare NSC