Provider Demographics
NPI:1518199371
Name:WATERLOO OPHTHALMIC DISPENSING, PC
Entity Type:Organization
Organization Name:WATERLOO OPHTHALMIC DISPENSING, PC
Other - Org Name:WATERLOO EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:315-539-1209
Mailing Address - Street 1:204 MAIN STREET SHOP CTR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1454
Mailing Address - Country:US
Mailing Address - Phone:315-539-1209
Mailing Address - Fax:315-539-1425
Practice Address - Street 1:204 MAIN STREET SHOP CTR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1454
Practice Address - Country:US
Practice Address - Phone:315-539-1209
Practice Address - Fax:315-539-1425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC004107-1332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5944090001Medicare UPIN