Provider Demographics
NPI:1861442022
Name:MODERN OPTIKA ,INC
Entity Type:Organization
Organization Name:MODERN OPTIKA ,INC
Other - Org Name:MODERN OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DONDE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-336-1060
Mailing Address - Street 1:453 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-1803
Mailing Address - Country:US
Mailing Address - Phone:718-336-1060
Mailing Address - Fax:718-336-0113
Practice Address - Street 1:453 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-1803
Practice Address - Country:US
Practice Address - Phone:718-336-1060
Practice Address - Fax:718-336-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0071631156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02376167Medicaid
NY02376167Medicaid
NY4852770001Medicare NSC