Provider Demographics
NPI:1831275510
Name:NOSTRAND OPTICAL, INC
Entity type:Organization
Organization Name:NOSTRAND OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:VALERY
Authorized Official - Last Name:SUPITSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:718-773-9391
Mailing Address - Street 1:1018C NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-3509
Mailing Address - Country:US
Mailing Address - Phone:718-773-9391
Mailing Address - Fax:718-773-9391
Practice Address - Street 1:1018C NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-3509
Practice Address - Country:US
Practice Address - Phone:718-773-9391
Practice Address - Fax:718-773-9391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0056301152W00000X
NY007691-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02241032Medicaid
NY02241032Medicaid
NYCIW821Medicare ID - Type Unspecified