Provider Demographics
NPI:1376839514
Name:FORREST-FOX, YANIQUE (OD)
Entity type:Individual
Prefix:
First Name:YANIQUE
Middle Name:
Last Name:FORREST-FOX
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:YANIQUE
Other - Middle Name:
Other - Last Name:FORREST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:601 SUFFOLK AVE.
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4309
Mailing Address - Country:US
Mailing Address - Phone:631-273-3335
Mailing Address - Fax:631-273-0310
Practice Address - Street 1:601 SUFFOLK AVE.
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4309
Practice Address - Country:US
Practice Address - Phone:631-273-3335
Practice Address - Fax:631-273-0310
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007702152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400052437Medicare PIN