Provider Demographics
NPI:1861444762
Name:KANE, ROBERT M (OPTDISP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:M
Last Name:KANE
Suffix:
Gender:M
Credentials:OPTDISP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4364
Mailing Address - Country:US
Mailing Address - Phone:718-336-0600
Mailing Address - Fax:718-336-0649
Practice Address - Street 1:2115 E 15TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4364
Practice Address - Country:US
Practice Address - Phone:718-336-0600
Practice Address - Fax:718-336-0649
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5907152W00000X
NY4019156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01151940Medicaid
NY01151940Medicaid