Healthcare Provider Details

I. General information

NPI: 1760228365
Provider Name (Legal Business Name): EVA JIA WEN QIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2094 ALBANY POST ROAD OPTOMETRY 620-123
MONTROSE NY
10548-0100
US

IV. Provider business mailing address

21 FREDETTE RD
NEWTON MA
02459-3704
US

V. Phone/Fax

Practice location:
  • Phone: 914-737-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberORT009968-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: