Provider Demographics
NPI:1780109447
Name:MCC OPTOMETRY OF ROOSEVELT PLLC
Entity type:Organization
Organization Name:MCC OPTOMETRY OF ROOSEVELT PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY CLAIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARANDANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-427-4795
Mailing Address - Street 1:39-38 62ND STREET
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3632
Mailing Address - Country:US
Mailing Address - Phone:718-427-4795
Mailing Address - Fax:
Practice Address - Street 1:3938 62ND ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3632
Practice Address - Country:US
Practice Address - Phone:718-427-4795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty