Healthcare Provider Details

I. General information

NPI: 1326143173
Provider Name (Legal Business Name): PINE BUSH OPTOMETRIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MAIN STREET
PINE BUSH NY
12566
US

IV. Provider business mailing address

PO BOX 949
PINE BUSH NY
12566-0949
US

V. Phone/Fax

Practice location:
  • Phone: 845-744-2003
  • Fax: 845-744-6260
Mailing address:
  • Phone: 845-744-2003
  • Fax: 845-744-6260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV006249-1
License Number StateNY

VIII. Authorized Official

Name: DR. RICHARD PAGAN
Title or Position: OWNER
Credential: OD
Phone: 845-744-2003