Provider Demographics
NPI:1568481752
Name:GREAT NORTHERN OPTICAL EQUIPMENT INC.
Entity Type:Organization
Organization Name:GREAT NORTHERN OPTICAL EQUIPMENT INC.
Other - Org Name:STERLING OPTICAL 291
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:AZZOTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-622-4607
Mailing Address - Street 1:7903 BREWERTON RD
Mailing Address - Street 2:WEST MARINE PLAZA
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-9531
Mailing Address - Country:US
Mailing Address - Phone:315-699-1700
Mailing Address - Fax:315-699-1700
Practice Address - Street 1:7903 BREWERTON RD
Practice Address - Street 2:WEST MARINE PLAZA
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-9531
Practice Address - Country:US
Practice Address - Phone:315-699-1700
Practice Address - Fax:315-699-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003420-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01808566Medicaid