Provider Demographics
NPI:1730467713
Name:RADOV, MIRIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:
Last Name:RADOV
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 VETERANS RD W
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 VETERANS RD W
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-2502
Practice Address - Country:US
Practice Address - Phone:718-227-3593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007250152W00000X
NJ27OA00589600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist