Healthcare Provider Details

I. General information

NPI: 1740474402
Provider Name (Legal Business Name): LONG ISLAND VITREO RETINAL CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NORTHERN BLVD STE 216
GREAT NECK NY
11021-5200
US

IV. Provider business mailing address

600 NORTHERN BLVD STE 216
GREAT NECK NY
11021-5200
US

V. Phone/Fax

Practice location:
  • Phone: 516-466-0390
  • Fax: 516-466-4956
Mailing address:
  • Phone: 516-466-0390
  • Fax: 516-466-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM MACCARONE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 516-466-0390