Healthcare Provider Details

I. General information

NPI: 1902044829
Provider Name (Legal Business Name): COSMOS TOTAL OPTOMETRY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90-01 ROOSEVELT AVENUE
JACKSON HEIGHTS NY
11372
US

IV. Provider business mailing address

90-01 ROOSEVELT AVENUE
JACKSON HEIGHTS NY
11372
US

V. Phone/Fax

Practice location:
  • Phone: 718-458-8500
  • Fax: 718-424-3366
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number006061VUT
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberVUT006061
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberVUT006061
License Number StateNY

VIII. Authorized Official

Name: DR. JOANNE ECONOPOULY
Title or Position: OD, OWNER
Credential: OD
Phone: 718-458-8500