Healthcare Provider Details

I. General information

NPI: 1669526877
Provider Name (Legal Business Name): ALEKSANDR MISYUK OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 FULTON ST MY OPTICIAN NYC
NEW YORK NY
10038-2807
US

IV. Provider business mailing address

2955 SHELL RD #9-0
BROOKLYN NY
11224-3634
US

V. Phone/Fax

Practice location:
  • Phone: 212-693-1111
  • Fax:
Mailing address:
  • Phone: 917-750-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number007265
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: