Provider Demographics
NPI:1184805764
Name:WYNN, DEJUAN LAMONT (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:DEJUAN
Middle Name:LAMONT
Last Name:WYNN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-1320
Mailing Address - Country:US
Mailing Address - Phone:212-222-6100
Mailing Address - Fax:212-222-6606
Practice Address - Street 1:167 LENOX AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1320
Practice Address - Country:US
Practice Address - Phone:212-222-6100
Practice Address - Fax:212-222-6606
Is Sole Proprietor?:No
Enumeration Date:2007-11-24
Last Update Date:2007-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164759156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician