Provider Demographics
NPI:1659336055
Name:FACCHIN, JOHN A (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:FACCHIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 GRAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758
Mailing Address - Country:US
Mailing Address - Phone:516-798-2635
Mailing Address - Fax:516-798-0896
Practice Address - Street 1:111 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758
Practice Address - Country:US
Practice Address - Phone:516-798-2635
Practice Address - Fax:516-798-0896
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0052761152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01474419Medicaid
U48040Medicare UPIN
NY0978400001Medicare NSC
NY01474419Medicaid