=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285768036
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIKE GHOSSN OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 12/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3270 HEMPSTEAD TPKE
-----------------------------------------------------
City | LEVITTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11756-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-731-5050
-----------------------------------------------------
Fax | 516-731-4900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 GLEASON DR
-----------------------------------------------------
City | DIX HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-6535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-242-9534
-----------------------------------------------------
Fax | 516-731-4900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 004407
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------