Provider Demographics
NPI:1578815320
Name:MDA OPTICAL LAB CORPORATION
Entity Type:Organization
Organization Name:MDA OPTICAL LAB CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LITOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-436-1848
Mailing Address - Street 1:1797 STILLWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-1037
Mailing Address - Country:US
Mailing Address - Phone:718-436-1848
Mailing Address - Fax:
Practice Address - Street 1:119 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3917
Practice Address - Country:US
Practice Address - Phone:718-436-1848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicare PIN