MEDICARE: NA MA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	250375	NY

General Provider Information

NPI Number	:	1033381983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NA MA MD

Provider Business Mailing Address
First Line	:	39 KINGS POINT RD
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11024-1635
Country	:	US
Telephone Number	:	516-385-9186
Fax Number	:

Provider Business Practice Location Address
First Line	:	39 KINGS POINT RD
Second Line	:
City	:	GREAT NECK
State	:	NY
Zip	:	11024-1635
Country	:	US
Telephone Number	:	516-385-9186
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	08/27/2010

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