MEDICARE: MARIO CALDERON

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	156FX1800X	Optician

General Provider Information

NPI Number	:	1235744681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO CALDERON

Provider Business Mailing Address
First Line	:	2894 LONG BEACH RD
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-3114
Country	:	US
Telephone Number	:	516-888-1038
Fax Number	:

Provider Business Practice Location Address
First Line	:	2894 LONG BEACH RD
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-3114
Country	:	US
Telephone Number	:	516-888-1038
Fax Number	:

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

Provider Enumeration Date	:	09/12/2020
Last Update Date	:	09/12/2020

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Directions to “ MARIO CALDERON ” Practice Location

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