Provider Demographics
NPI:1891982476
Name:SOUTH FORK OPTICAL CENTER, INC.
Entity Type:Organization
Organization Name:SOUTH FORK OPTICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:TSCHUBARJAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:631-728-1525
Mailing Address - Street 1:1 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-2018
Mailing Address - Country:US
Mailing Address - Phone:631-728-1525
Mailing Address - Fax:631-728-1534
Practice Address - Street 1:1 JACKSON AVE SOUTH
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-2018
Practice Address - Country:US
Practice Address - Phone:631-728-1525
Practice Address - Fax:631-728-1534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4065332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4024020001Medicare NSC