Provider Demographics
NPI:1255084729
Name:MIDDLETOWN EYE CARE OD PC
Entity type:Organization
Organization Name:MIDDLETOWN EYE CARE OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:845-692-0709
Mailing Address - Street 1:1 NORTH GALLERIA DRIVE STE 26
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-3018
Mailing Address - Country:US
Mailing Address - Phone:845-692-0709
Mailing Address - Fax:
Practice Address - Street 1:1 NORTH GALLERIA DRIVE STE 26
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-3018
Practice Address - Country:US
Practice Address - Phone:845-692-0709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDDLETOWN EYE CARE OD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1760683437Medicaid
NY1700088481Medicaid