Provider Demographics
NPI:1336577493
Name:SANPAUL, SURESH (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:SURESH
Middle Name:
Last Name:SANPAUL
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 1:9065 180TH ST PH
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-5612
Mailing Address - Country:US
Mailing Address - Phone:718-297-2997
Mailing Address - Fax:718-880-9849
Practice Address - Street 1:18116 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4852
Practice Address - Country:US
Practice Address - Phone:718-297-2997
Practice Address - Fax:188-809-8497
Is Sole Proprietor?:No
Enumeration Date:2013-10-28
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005810156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03978205Medicaid