Healthcare Provider Details

I. General information

NPI: 1003973223
Provider Name (Legal Business Name): CRESTON OPTICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2169 WHITE PLAINS RD
BRONX NY
10462-1405
US

IV. Provider business mailing address

2169 WHITE PLAINS RD
BRONX NY
10462-1405
US

V. Phone/Fax

Practice location:
  • Phone: 718-409-2200
  • Fax:
Mailing address:
  • Phone: 718-409-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberVUT002933-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberVUT002933-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberVUT002933-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberVUT002933-1
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number005104-1
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number005104-1
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number005104-1
License Number StateNY
# 8
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT002933-1
License Number StateNY

VIII. Authorized Official

Name: MR. DOUGLAS T BERGER
Title or Position: MGR
Credential: OPTICIAN
Phone: 718-409-2200