Provider Demographics
NPI:1760435374
Name:CLEMENT IDEHEN OPTOMETRIST PC
Entity Type:Organization
Organization Name:CLEMENT IDEHEN OPTOMETRIST PC
Other - Org Name:EYESITE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:ENORENSE
Authorized Official - Last Name:IDEHEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-628-9200
Mailing Address - Street 1:5546 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3554
Mailing Address - Country:US
Mailing Address - Phone:718-628-9200
Mailing Address - Fax:718-628-5600
Practice Address - Street 1:5546 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-3554
Practice Address - Country:US
Practice Address - Phone:718-628-9200
Practice Address - Fax:718-628-5600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT006065152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02263261Medicaid
NY02263261Medicaid