Provider Demographics
NPI:1942534078
Name:1038 SB OPTICAL CORP
Entity Type:Organization
Organization Name:1038 SB OPTICAL CORP
Other - Org Name:METRO OPTICS EYEWEAR III
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:YAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-328-7137
Mailing Address - Street 1:1038 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-3407
Mailing Address - Country:US
Mailing Address - Phone:718-328-7137
Mailing Address - Fax:
Practice Address - Street 1:1038 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-3407
Practice Address - Country:US
Practice Address - Phone:718-328-7137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03168967Medicaid
NYA100077950Medicare PIN