Healthcare Provider Details

I. General information

NPI: 1174830988
Provider Name (Legal Business Name): SUNNYSIDE OPTOMETRY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 QUEENS BLVD SUITE NUMBER 303
SUNNYSIDE NY
11104-1600
US

IV. Provider business mailing address

7 SINCLAIR MARTIN DR
ROSLYN NY
11576-1184
US

V. Phone/Fax

Practice location:
  • Phone: 516-801-6323
  • Fax: 888-314-7302
Mailing address:
  • Phone: 516-801-6323
  • Fax: 888-314-7302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT006238
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT006238
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberT006238
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberT006238
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL VARUJAN KALUSTIAN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 516-801-6323