Provider Demographics
NPI:1932239191
Name:DAVIDOV, JACOB (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DAVIDOV
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9309 63RD DR # A
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2924
Mailing Address - Country:US
Mailing Address - Phone:718-275-0955
Mailing Address - Fax:718-275-3725
Practice Address - Street 1:9309 63RD DR # A
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2924
Practice Address - Country:US
Practice Address - Phone:718-275-0955
Practice Address - Fax:718-275-3725
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006154-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician