Provider Demographics
NPI:1255419180
Name:MINKOFF, ARLENE EDITH (OD)
Entity type:Individual
Prefix:
First Name:ARLENE
Middle Name:EDITH
Last Name:MINKOFF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BEACON DR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4309
Mailing Address - Country:US
Mailing Address - Phone:631-563-0072
Mailing Address - Fax:
Practice Address - Street 1:125 BEACON DR
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4309
Practice Address - Country:US
Practice Address - Phone:631-563-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004286-1152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
C429B1Medicare ID - Type Unspecified
V07703Medicare UPIN