Provider Demographics
NPI:1619040730
Name:BERENZON, LEONID (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:LEONID
Middle Name:
Last Name:BERENZON
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6603 BAY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-3934
Mailing Address - Country:US
Mailing Address - Phone:718-259-8489
Mailing Address - Fax:718-236-4565
Practice Address - Street 1:6603 BAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3934
Practice Address - Country:US
Practice Address - Phone:718-259-8489
Practice Address - Fax:718-236-4565
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006451156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician