=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568568731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESMOND OPTICAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 178 PARK PL
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11238-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-623-9122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 178 PARK PL
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11238-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-623-9122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MS. MARILYN FIGUEROA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-623-9122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | VUT004926
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------