Healthcare Provider Details

I. General information

NPI: 1417920042
Provider Name (Legal Business Name): MIRKIN VISION CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 BEACH 116TH ST
ROCKAWAY PARK NY
11694-2102
US

IV. Provider business mailing address

253 BEACH 116TH ST
ROCKAWAY PARK NY
11694-2102
US

V. Phone/Fax

Practice location:
  • Phone: 718-634-0005
  • Fax: 718-474-2003
Mailing address:
  • Phone: 718-634-0005
  • Fax: 718-474-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberVUT004688
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberVUT004688
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number004688
License Number StateNY

VIII. Authorized Official

Name: PROF. DANIEL S MIRKIN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 718-634-0005