Provider Demographics
NPI:1891999769
Name:P. WOODYEAR CORP.
Entity Type:Organization
Organization Name:P. WOODYEAR CORP.
Other - Org Name:FAR ROCKAWAY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:YEARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-337-2020
Mailing Address - Street 1:1304 BEACH CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3206
Mailing Address - Country:US
Mailing Address - Phone:718-337-2020
Mailing Address - Fax:718-337-2257
Practice Address - Street 1:1304 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3206
Practice Address - Country:US
Practice Address - Phone:718-337-2020
Practice Address - Fax:718-337-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2105152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02061383Medicaid
NY05296Medicare PIN