Provider Demographics
NPI:1740549443
Name:VALENTIN RAKSIN, O.D., PC
Entity type:Organization
Organization Name:VALENTIN RAKSIN, O.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VALENTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAKSIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-377-5649
Mailing Address - Street 1:426 DANBURY LN
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-5116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1823 AVENUE M
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5308
Practice Address - Country:US
Practice Address - Phone:718-377-5649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006253-1261QH0100X
NJ27OA00578000261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02087227Medicaid
NJ8933308Medicaid
NYU81815Medicare UPIN
NY02087227Medicaid
NJ064956Medicare PIN