Provider Demographics
NPI:1922104785
Name:OPTICAL CHOICE CORP
Entity Type:Organization
Organization Name:OPTICAL CHOICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PINKHOZ
Authorized Official - Middle Name:
Authorized Official - Last Name:YUSUPOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-793-2461
Mailing Address - Street 1:11811 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11811 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7202
Practice Address - Country:US
Practice Address - Phone:718-793-2461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007169-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02245238Medicaid
NY02245238Medicaid
NY05652GMedicare ID - Type Unspecified
NYG100011190Medicare PIN