Provider Demographics
NPI:1720353667
Name:BEN-JACOB, BOAZ
Entity Type:Individual
Prefix:
First Name:BOAZ
Middle Name:
Last Name:BEN-JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2400
Mailing Address - Country:US
Mailing Address - Phone:516-616-1771
Mailing Address - Fax:
Practice Address - Street 1:1445 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-2400
Practice Address - Country:US
Practice Address - Phone:516-616-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-10
Last Update Date:2012-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007987156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician