Provider Demographics
NPI:1568405629
Name:MEDPLAZA OPTICAL INC
Entity Type:Organization
Organization Name:MEDPLAZA OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVBASYUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-332-5047
Mailing Address - Street 1:3065 BRIGHTON 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5501
Mailing Address - Country:US
Mailing Address - Phone:718-332-5047
Mailing Address - Fax:
Practice Address - Street 1:3065 BRIGHTON 14TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5501
Practice Address - Country:US
Practice Address - Phone:718-332-5047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT006567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02409043Medicaid
NY02409043Medicaid