Healthcare Provider Details

I. General information

NPI: 1124133145
Provider Name (Legal Business Name): VALERY NAYMAGON OPHTHALMIC DISPENSER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 WILLIAMSON ST SUITE 505
ELIZABETH NJ
07202-3674
US

IV. Provider business mailing address

3108 NOSTRAND AVE
BROOKLYN NY
11229-2601
US

V. Phone/Fax

Practice location:
  • Phone: 908-289-0250
  • Fax: 908-289-3713
Mailing address:
  • Phone: 718-594-2793
  • Fax: 908-289-3713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number31TD00337700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: