Provider Demographics
NPI:1598867418
Name:CHAVIS, RICHARD
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:CHAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 PEBBLE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-4317
Mailing Address - Country:US
Mailing Address - Phone:845-208-3345
Mailing Address - Fax:845-208-3344
Practice Address - Street 1:187 E 116TH ST
Practice Address - Street 2:WIZARD OF EYES
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-1342
Practice Address - Country:US
Practice Address - Phone:212-996-7676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006252156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01371815Medicaid