Provider Demographics
NPI:1659406023
Name:NACINOVICH, WALTER SERGIO (OPHTHALMIC DISPENSER)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:SERGIO
Last Name:NACINOVICH
Suffix:
Gender:M
Credentials:OPHTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VIOLA DR
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-3349
Mailing Address - Country:US
Mailing Address - Phone:516-671-0912
Mailing Address - Fax:
Practice Address - Street 1:221-04B HORACE HARDING EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364
Practice Address - Country:US
Practice Address - Phone:718-225-7400
Practice Address - Fax:718-225-7607
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3755156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician