Provider Demographics
NPI:1932138112
Name:QUEENS OPHTHALMOLOGY PC
Entity Type:Organization
Organization Name:QUEENS OPHTHALMOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PANUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMSAITONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-380-8050
Mailing Address - Street 1:440 W BAY DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1838
Mailing Address - Country:US
Mailing Address - Phone:718-380-8050
Mailing Address - Fax:718-380-5303
Practice Address - Street 1:5115 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1042
Practice Address - Country:US
Practice Address - Phone:718-380-8050
Practice Address - Fax:718-380-5303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02698653Medicaid
NY02698653Medicaid