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General NPI Number Information
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NPI Number | 1386101632
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Entity Type | Organization
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Legal Business Name | OPTICAL SHOP OF DEER PARK INC
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Dates
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Enumeration Date | 02/22/2019
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Last Update Date | 07/02/2019
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Provider Practice Location Address
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Address Line | 415 COMMACK RD STE 2B
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City | DEER PARK
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State | NY
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Zip | 11729-4508
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Country | US
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Telephone | 631-392-0711
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Fax | 631-392-0752
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Provider Business Mailing Address
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Address Line | 415 COMMACK RD STE 2B
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City | DEER PARK
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State | NY
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Zip | 11729-4508
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Country | US
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Telephone | 631-392-0711
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Fax | 631-392-0752
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Authorized Official
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Title or Position | OWNER
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Name | LEONID GLADSTEIN
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Credential |
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Telephone | 917-887-8872
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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