Healthcare Provider Details

I. General information

NPI: 1063549541
Provider Name (Legal Business Name): ALAN FRUCHTMAN OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 VICTORY BLVD
STATEN ISLAND NY
10314-3515
US

IV. Provider business mailing address

1803 VICTORY BLVD
STATEN ISLAND NY
10314-3515
US

V. Phone/Fax

Practice location:
  • Phone: 718-448-7676
  • Fax: 718-448-7675
Mailing address:
  • Phone: 718-448-7676
  • Fax: 718-448-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number4036
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: