Healthcare Provider Details

I. General information

NPI: 1194226886
Provider Name (Legal Business Name): ESAD OPTICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6332 NORTHERN BLVD
EAST NORWICH NY
11732-1600
US

IV. Provider business mailing address

708 SEABURY AVE
FRANKLIN SQUARE NY
11010-4112
US

V. Phone/Fax

Practice location:
  • Phone: 516-624-3149
  • Fax:
Mailing address:
  • Phone: 516-641-1768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTUV004987
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberTUV004987
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV004987
License Number StateNY

VIII. Authorized Official

Name: DR. ELISA F DE JUNCO
Title or Position: PRESIDENT
Credential: OD
Phone: 516-641-1768