MEDICARE: 1038 SB OPTICAL CORP

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
2	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942534078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1038 SB OPTICAL CORP

Provider Business Mailing Address
First Line	:	1038 SOUTHERN BLVD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10459-3407
Country	:	US
Telephone Number	:	718-328-7137
Fax Number	:

Provider Business Practice Location Address
First Line	:	1038 SOUTHERN BLVD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10459-3407
Country	:	US
Telephone Number	:	718-328-7137
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OPTOMETRIST
Name	:	DR. EVA YAN
Credential	:	O.D.
Telephone Number	:	718-328-7137

Provider Enumeration Date	:	09/22/2009
Last Update Date	:	04/16/2013

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Directions to “1038 SB OPTICAL CORP ” Practice Location

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