=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124118922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSAL OPTOMETRY P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 09/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7259 KISSENA BLVD
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11367-2723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-896-1934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7259 KISSENA BLVD
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11367-2723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-896-1934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATION
-----------------------------------------------------
Name | MS. CAROL SIDHAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-896-1934
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV 006926
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------