Provider Demographics
NPI:1578742797
Name:PLAZA OPTICAL OF MONROE, INC
Entity Type:Organization
Organization Name:PLAZA OPTICAL OF MONROE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:UTNICK
Authorized Official - Suffix:
Authorized Official - Credentials:OPHTHALMIC DISTPENSE
Authorized Official - Phone:845-783-4400
Mailing Address - Street 1:475 STATE ROUTE 17M
Mailing Address - Street 2:PLAZA OPTICAL
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-4169
Mailing Address - Country:US
Mailing Address - Phone:845-783-4400
Mailing Address - Fax:845-782-4041
Practice Address - Street 1:475 STATE ROUTE 17M
Practice Address - Street 2:PLAZA OPTICAL
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4169
Practice Address - Country:US
Practice Address - Phone:845-783-4400
Practice Address - Fax:845-782-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYUT5263152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU32923OtherBLUECROSS BLUESHIELD