Provider Demographics
NPI:1689928293
Name:DUBOURG, LOUISEMENE (OPTICAN)
Entity Type:Individual
Prefix:
First Name:LOUISEMENE
Middle Name:
Last Name:DUBOURG
Suffix:
Gender:F
Credentials:OPTICAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 FULTON ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2505
Mailing Address - Country:US
Mailing Address - Phone:646-346-3382
Mailing Address - Fax:
Practice Address - Street 1:1480 FULTON ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2505
Practice Address - Country:US
Practice Address - Phone:646-346-3382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-04
Last Update Date:2012-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT5575152W00000X
NY55 009252156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY900883361OtherBLUE CROSS, BLUE SHIELD, AETNA, KAISER-PERMANENTE,DAVIS VISION, HEALTH FIRST.
NY900883361Medicaid
NY900883361Medicare PIN