Provider Demographics
NPI:1881782951
Name:COOPERSTOWN OPTICAL
Entity type:Organization
Organization Name:COOPERSTOWN OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:MURDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-547-8080
Mailing Address - Street 1:PO BOX 1170
Mailing Address - Street 2:5370 STATE HWY 28
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-6170
Mailing Address - Country:US
Mailing Address - Phone:607-547-8080
Mailing Address - Fax:607-547-2152
Practice Address - Street 1:5370 STATE HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-5710
Practice Address - Country:US
Practice Address - Phone:607-547-8080
Practice Address - Fax:607-547-2152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV 006437152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10061773OtherCDPHP
NY1050OtherRMSCO
NY1050OtherRMSCO
NYBA0343Medicare ID - Type UnspecifiedMEDICARE
NY10061773OtherCDPHP