Provider Demographics
NPI:1336360767
Name:OMEGA OPTICAL INC
Entity Type:Organization
Organization Name:OMEGA OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIMANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-897-5101
Mailing Address - Street 1:9102 63RD DR
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3850
Mailing Address - Country:US
Mailing Address - Phone:718-897-5101
Mailing Address - Fax:
Practice Address - Street 1:9102 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3850
Practice Address - Country:US
Practice Address - Phone:718-897-5101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7240-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNY7240OtherEYE MED VISION CARE
NY02181684Medicaid
NYP3693521OtherOXFORD
NY14913OtherSPECTERA
NY46613OtherAVESIS
NYNY7240OtherEYE MED VISION CARE