Provider Demographics
NPI:1518260769
Name:MOSTOVOY, ROMAN (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:MOSTOVOY
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4133
Mailing Address - Country:US
Mailing Address - Phone:347-587-6565
Mailing Address - Fax:
Practice Address - Street 1:711 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-4133
Practice Address - Country:US
Practice Address - Phone:347-587-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC009086156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician