Provider Demographics
NPI:1841243458
Name:MANEVICH, TATYANA (OPTICIAN)
Entity Type:Individual
Prefix:MS
First Name:TATYANA
Middle Name:
Last Name:MANEVICH
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 BRIGHTON BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5658
Mailing Address - Country:US
Mailing Address - Phone:718-332-4704
Mailing Address - Fax:718-615-4739
Practice Address - Street 1:944 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2338
Practice Address - Country:US
Practice Address - Phone:718-332-4704
Practice Address - Fax:718-615-4739
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005712156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician