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General NPI Number Information
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NPI Number | 1811066111
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Entity Type | Organization
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Legal Business Name | OPTICAL WAREHOUSE OUTLET OF WIILIAMSBURGE
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 366 GRAHAM AVE
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City | BROOKLYN
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State | NY
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Zip | 11211-2410
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Country | US
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Telephone | 718-388-3300
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Fax |
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Provider Business Mailing Address
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Address Line | 366 GRAHAM AVE
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City | BROOKLYN
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State | NY
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Zip | 11211-2410
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Country | US
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Telephone | 718-388-3300
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. VADIM KRUZHKOV
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Credential | OPTICIAN
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Telephone | 718-388-3300
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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 | T6451-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 007005
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License Number State | NY
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