=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750555843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTOMETRY ASSOCIATES OF WANTAGH, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2008
-----------------------------------------------------
Last Update Date | 11/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3448 JERUSALEM AVE
-----------------------------------------------------
City | WANTAGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11793-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-781-2822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3448 JERUSALEM AVE
-----------------------------------------------------
City | WANTAGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11793-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-781-2822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NEIL RUBIN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 516-781-2822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV4934
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------