Provider Demographics
NPI:1619500964
Name:RAPHAEL OPTICAL INC.
Entity Type:Organization
Organization Name:RAPHAEL OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDOV
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:718-456-2752
Mailing Address - Street 1:303 WYCKOFF AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-5805
Mailing Address - Country:US
Mailing Address - Phone:718-456-2752
Mailing Address - Fax:718-456-2753
Practice Address - Street 1:303 WYCKOFF AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-5805
Practice Address - Country:US
Practice Address - Phone:718-456-2752
Practice Address - Fax:718-456-2753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01463758Medicaid