Provider Demographics
NPI:1710936059
Name:SOUTH SHORE OPTOMETRIC ASSOCIATES, PC
Entity Type:Organization
Organization Name:SOUTH SHORE OPTOMETRIC ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:LEIBSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:631-264-3937
Mailing Address - Street 1:202 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2727
Mailing Address - Country:US
Mailing Address - Phone:631-264-3937
Mailing Address - Fax:631-598-4496
Practice Address - Street 1:202 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2797
Practice Address - Country:US
Practice Address - Phone:631-264-3937
Practice Address - Fax:631-598-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005756-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03196247Medicaid
NYCAWKV1Medicare UPIN