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General NPI Number Information
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NPI Number | 1801041843
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Entity Type | Individual
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Provider Name | PAUL MASTROROCCO DISPENSING OPTICIAN
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Gender | Male
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Dates
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Enumeration Date | 11/18/2008
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Last Update Date | 09/17/2021
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Provider Practice Location Address
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Address Line | 208 ROUTE 112 STE 2
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-1013
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Country | US
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Telephone | 631-331-0600
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Fax | 631-331-0809
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Provider Business Mailing Address
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Address Line | 180 E MAIN ST SUITE 104
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City | PATCHOGUE
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State | NY
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Zip | 11772-3171
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Country | US
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Telephone | 631-475-5030
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Fax | 631-475-5037
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 5855-1
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License Number State | NY
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