MEDICARE: EVA JIA WEN QIU

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	ORT009968-01	NY

General Provider Information

NPI Number	:	1760228365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVA JIA WEN QIU

Provider Business Mailing Address
First Line	:	21 FREDETTE RD
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02459-3704
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2094 ALBANY POST ROAD
Second Line	:	OPTOMETRY 620-123
City	:	MONTROSE
State	:	NY
Zip	:	10548-0100
Country	:	US
Telephone Number	:	914-737-4400
Fax Number	:

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

Provider Enumeration Date	:	07/02/2024
Last Update Date	:	07/02/2024

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