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General NPI Number Information
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NPI Number | 1902184641
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Entity Type | Organization
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Legal Business Name | OPTIMUM OPTOMETRY & OPHTHALMIC DISPENSING EYECARE PLLC
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Dates
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Enumeration Date | 07/29/2011
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Last Update Date | 07/29/2011
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Provider Practice Location Address
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Address Line | 3117 23RD AVE
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City | ASTORIA
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State | NY
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Zip | 11105-2488
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Country | US
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Telephone | 718-626-9400
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Fax | 718-626-9499
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Provider Business Mailing Address
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Address Line | 3117 23RD AVE
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City | ASTORIA
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State | NY
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Zip | 11105-2488
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Country | US
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Telephone | 718-626-9400
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Fax | 718-626-9499
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Authorized Official
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Title or Position | COOWNER
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Name | MR. ALEXANDR KOZOCHONOK
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Credential |
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Telephone | 19174203824
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 55008562
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License Number State | NY
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