Provider Demographics
NPI:1720012891
Name:HELLER, PAUL L (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:L
Last Name:HELLER
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 W MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3712
Mailing Address - Country:US
Mailing Address - Phone:516-867-1213
Mailing Address - Fax:516-867-1214
Practice Address - Street 1:185 W MERRICK RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3712
Practice Address - Country:US
Practice Address - Phone:516-867-1213
Practice Address - Fax:516-867-1214
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4715156FX1800X
NY6545156FX1800X
NYTUV004726-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00847345Medicaid
NYWWA661Medicare PIN
NY00847345Medicaid