Provider Demographics
NPI:1659325231
Name:UNDERGROUND EYEWEAR INC
Entity Type:Organization
Organization Name:UNDERGROUND EYEWEAR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DESMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-282-8363
Mailing Address - Street 1:4807 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-3334
Mailing Address - Country:US
Mailing Address - Phone:718-282-8363
Mailing Address - Fax:718-282-7630
Practice Address - Street 1:4807 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3334
Practice Address - Country:US
Practice Address - Phone:718-282-8363
Practice Address - Fax:718-282-7630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2023-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01765782Medicaid
NY01765782Medicaid