MEDICARE: MIDWOOD OPTICAL LLC

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

General Provider Information

NPI Number	:	1790328128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWOOD OPTICAL LLC

Provider Business Mailing Address
First Line	:	1811 AVENUE M
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5308
Country	:	US
Telephone Number	:	718-684-6905
Fax Number	:

Provider Business Practice Location Address
First Line	:	1811 AVENUE M
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5308
Country	:	US
Telephone Number	:	718-684-6905
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JONATHAN FABIAN
Credential	:
Telephone Number	:	718-764-3271

Provider Enumeration Date	:	10/17/2019
Last Update Date	:	10/17/2019

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Directions to “MIDWOOD OPTICAL LLC ” Practice Location

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