Healthcare Provider Details

I. General information

NPI: 1629337167
Provider Name (Legal Business Name): BAHUR YACOBOV OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8113 LEFFERTS BLVD
KEW GARDENS NY
11415-1727
US

IV. Provider business mailing address

8113 LEFFERTS BLVD
KEW GARDENS NY
11415-1727
US

V. Phone/Fax

Practice location:
  • Phone: 718-849-0847
  • Fax: 718-849-0864
Mailing address:
  • Phone: 718-849-0847
  • Fax: 718-849-0864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number6538
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: