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General NPI Number Information
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NPI Number | 1356633937
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Entity Type | Organization
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Legal Business Name | CRYSTAL OPTOMETRIC EYECARE, P.C.
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Dates
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Enumeration Date | 05/13/2011
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Last Update Date | 05/13/2011
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Provider Practice Location Address
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Address Line | 300 ROUTE 18 MIDSTATE MALL, SUITE#32B
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-1912
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Country | US
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Telephone | 732-651-8188
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Fax | 732-651-8199
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Provider Business Mailing Address
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Address Line | 18015 64TH AVE
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City | FRESH MEADOWS
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State | NY
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Zip | 11365-2101
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Country | US
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Telephone | 718-595-2266
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Fax | 718-595-2292
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DEREK CHONG
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Credential | O.D.
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Telephone | 718-595-2266
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 27OA00582400
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 27OA00612000
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License Number State | NJ
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