Provider Demographics
NPI:1669681706
Name:DA OPTICAL
Entity type:Organization
Organization Name:DA OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DENUNIZOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-631-3699
Mailing Address - Street 1:21151 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2492
Mailing Address - Country:US
Mailing Address - Phone:718-631-3699
Mailing Address - Fax:718-631-7319
Practice Address - Street 1:21151 26TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2492
Practice Address - Country:US
Practice Address - Phone:718-631-3699
Practice Address - Fax:718-631-7319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT003266-1302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6183100001Medicare NSC
NYG100000267Medicare PIN