Healthcare Provider Details

I. General information

NPI: 1295143287
Provider Name (Legal Business Name): ATHINA DOULAVERIS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 DEER PARK AVE
DEER PARK NY
11729-4301
US

IV. Provider business mailing address

1806 DEER PARK AVE
DEER PARK NY
11729-4301
US

V. Phone/Fax

Practice location:
  • Phone: 631-667-4166
  • Fax: 631-685-7274
Mailing address:
  • Phone: 631-667-4166
  • Fax: 631-685-7274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV008196
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: