Provider Demographics
NPI:1902184641
Name:OPTIMUM OPTOMETRY & OPHTHALMIC DISPENSING EYECARE PLLC
Entity Type:Organization
Organization Name:OPTIMUM OPTOMETRY & OPHTHALMIC DISPENSING EYECARE PLLC
Other - Org Name:OPTIMUM EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZOCHONOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1917-420-3824
Mailing Address - Street 1:3117 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2488
Mailing Address - Country:US
Mailing Address - Phone:718-626-9400
Mailing Address - Fax:718-626-9499
Practice Address - Street 1:3117 23RD AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2488
Practice Address - Country:US
Practice Address - Phone:718-626-9400
Practice Address - Fax:718-626-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY55008562332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier