Provider Demographics
NPI:1982805750
Name:MIDCREST OPTICAL CORPORATION
Entity Type:Organization
Organization Name:MIDCREST OPTICAL CORPORATION
Other - Org Name:CRESTON OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-582-5926
Mailing Address - Street 1:897 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-5154
Mailing Address - Country:US
Mailing Address - Phone:212-582-5926
Mailing Address - Fax:
Practice Address - Street 1:897 8TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-5154
Practice Address - Country:US
Practice Address - Phone:212-582-5926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT002933-1152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X
NY5104-1156FC0801X
NY005104-1156FX1800X
NYC005104-1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00328267Medicaid
NYC5W011Medicare ID - Type Unspecified