MEDICARE: THE WANDERING EYE

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	152W00000X	Optometrist	007084	NY

General Provider Information

NPI Number	:	1093831497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE WANDERING EYE

Provider Business Mailing Address
First Line	:	526 NORTH 12TH ST
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-4340
Country	:	US
Telephone Number	:	516-318-5183
Fax Number	:

Provider Business Practice Location Address
First Line	:	526 NORTH 12TH ST
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-4340
Country	:	US
Telephone Number	:	516-318-5183
Fax Number	:

Authorized Official
Title or Position	:	OPTICIAN OWNER
Name	:	MR. JEFFREY S ROTH
Credential	:	FNAO
Telephone Number	:	516-378-5183

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	08/22/2020

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Directions to “THE WANDERING EYE ” Practice Location

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