Healthcare Provider Details

I. General information

NPI: 1922569136
Provider Name (Legal Business Name): MJD OPTICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 ROUTE 58 ROANOKE AVE
RIVERHEAD NY
11901
US

IV. Provider business mailing address

1053 ROUTE 58 ROANOKE AVE
RIVERHEAD NY
11901
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-7777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ROSS DEVORE
Title or Position: OWNER
Credential:
Phone: 631-727-7777