Provider Demographics
NPI:1821115155
Name:BROOKHAVEN OPTICIANS INC.
Entity Type:Organization
Organization Name:BROOKHAVEN OPTICIANS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTROROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:631-265-5767
Mailing Address - Street 1:79 E MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2867
Mailing Address - Country:US
Mailing Address - Phone:631-265-5767
Mailing Address - Fax:631-265-9624
Practice Address - Street 1:79 E MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2867
Practice Address - Country:US
Practice Address - Phone:631-265-5767
Practice Address - Fax:631-265-9624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC0058551332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00342952Medicaid