Healthcare Provider Details

I. General information

NPI: 1225203649
Provider Name (Legal Business Name): STARLIGHT OPTICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2008
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 GRAVESEND NECK RD
BROOKLYN NY
11229-4434
US

IV. Provider business mailing address

1501 GRAVESEND NECK RD
BROOKLYN NY
11229-4434
US

V. Phone/Fax

Practice location:
  • Phone: 718-787-4111
  • Fax: 718-787-4114
Mailing address:
  • Phone: 718-787-4111
  • Fax: 718-787-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTUV006443
License Number StateNY

VIII. Authorized Official

Name: DR. STANISLAV ILYUSHA
Title or Position: PRESIDENT
Credential:
Phone: 718-787-4111