=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063697043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYECARE BY OPHTHALMOLOGIST, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2008
-----------------------------------------------------
Last Update Date | 05/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 755 NEW YORK AVE SUITE 307
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-4240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-886-8830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8130 254TH ST
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11004-1438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-886-8830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | TUNG T CHU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-886-8830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 211188
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------