Provider Demographics
NPI:1649391285
Name:SUPERIOR VISION OF NEW YORK, INC.
Entity Type:Organization
Organization Name:SUPERIOR VISION OF NEW YORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-567-9351
Mailing Address - Street 1:4767 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-4915
Mailing Address - Country:US
Mailing Address - Phone:212-567-9351
Mailing Address - Fax:212-567-3370
Practice Address - Street 1:4767 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-4915
Practice Address - Country:US
Practice Address - Phone:212-567-9351
Practice Address - Fax:212-567-3370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003223-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01789688Medicaid