Healthcare Provider Details

I. General information

NPI: 1245195775
Provider Name (Legal Business Name): SUPREME OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 NOSTRAND AVE
BROOKLYN NY
11216-2013
US

IV. Provider business mailing address

200 W 125TH ST
NEW YORK NY
10027-4410
US

V. Phone/Fax

Practice location:
  • Phone: 718-230-0774
  • Fax: 929-234-3172
Mailing address:
  • Phone: 718-230-0774
  • Fax: 929-234-3172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: EDWARD BANGIYEV
Title or Position: OWNER
Credential:
Phone: 917-642-1035