Healthcare Provider Details

I. General information

NPI: 1346638434
Provider Name (Legal Business Name): ISLAND EYE OPTICAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2014
Last Update Date: 12/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 VICTORY BOULEVARD
STATEN ISLAND NY
10301
US

IV. Provider business mailing address

4299 HYLAN BLVD
STATEN ISLAND NY
10312-6527
US

V. Phone/Fax

Practice location:
  • Phone: 718-984-7616
  • Fax: 718-984-8584
Mailing address:
  • Phone: 718-984-7616
  • Fax: 718-984-8584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV0017979-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number004733-1
License Number StateNY

VIII. Authorized Official

Name: MICHAEL NEJAT
Title or Position: OWNER
Credential: MD
Phone: 718-984-7616