Healthcare Provider Details

I. General information

NPI: 1538617790
Provider Name (Legal Business Name): JACLYN BENZONI OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 03/31/2023
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2126 MERRICK MALL
MERRICK NY
11566-3626
US

IV. Provider business mailing address

2126 MERRICK MALL
MERRICK NY
11566-3626
US

V. Phone/Fax

Practice location:
  • Phone: 516-546-3227
  • Fax:
Mailing address:
  • Phone: 516-546-3227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007403-1
License Number StateNY

VIII. Authorized Official

Name: DR. JACLYN A BENZONI
Title or Position: CEO
Credential: O.D.
Phone: 516-721-7003