Provider Demographics
NPI:1982646477
Name:OPTICAL WAREHOUSE OUTLET OF BROOKLYN INC
Entity Type:Organization
Organization Name:OPTICAL WAREHOUSE OUTLET OF BROOKLYN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVYDOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-941-8585
Mailing Address - Street 1:844 FLATBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-3189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:844 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-3189
Practice Address - Country:US
Practice Address - Phone:718-941-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02385817Medicaid
NY01986263Medicaid
NYA100074160Medicare PIN
NYU01744Medicare UPIN
NY01986263Medicaid
NY02385817Medicaid