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General NPI Number Information
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NPI Number | 1568405629
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Entity Type | Organization
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Legal Business Name | MEDPLAZA OPTICAL INC
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Dates
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Enumeration Date | 06/14/2006
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Last Update Date | 11/23/2007
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Provider Practice Location Address
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Address Line | 3065 BRIGHTON 14TH ST
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City | BROOKLYN
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State | NY
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Zip | 11235-5501
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Country | US
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Telephone | 718-332-5047
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Fax |
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Provider Business Mailing Address
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Address Line | 3065 BRIGHTON 14TH ST
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City | BROOKLYN
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State | NY
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Zip | 11235-5501
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Country | US
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Telephone | 718-332-5047
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ALEXANDER KOVBASYUK
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Credential |
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Telephone | 718-332-5047
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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 | VUT006567
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License Number State | NY
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