Provider Demographics
NPI:1891722138
Name:EYESITE VISION III INCORPORATION
Entity Type:Organization
Organization Name:EYESITE VISION III INCORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:E
Authorized Official - Last Name:IDEHEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:917-650-0190
Mailing Address - Street 1:248 KENSINGTON
Mailing Address - Street 2:LYNBROOK
Mailing Address - City:LONG ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2711
Mailing Address - Country:US
Mailing Address - Phone:917-650-0190
Mailing Address - Fax:
Practice Address - Street 1:446 KNICKERBOCKER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4509
Practice Address - Country:US
Practice Address - Phone:718-455-6500
Practice Address - Fax:718-455-6507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT006065152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02705526Medicaid
NY02705526Medicaid
NY02705526Medicaid