MEDICARE: NEW YORK GLAUCOMA MEDICAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1013020296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW YORK GLAUCOMA MEDICAL PC

Provider Business Mailing Address
First Line	:	65 OCEANA DR E
Second Line	:	SUITE 5D
City	:	BROOKLYN
State	:	NY
Zip	:	11235-6686
Country	:	US
Telephone Number	:	718-645-2201
Fax Number	:	718-645-2207

Provider Business Practice Location Address
First Line	:	455 KINGS HWY
Second Line	:	1ST FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11223-1803
Country	:	US
Telephone Number	:	718-645-2201
Fax Number	:	718-645-2207

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IRINA PANKOVA
Credential	:	DO
Telephone Number	:	718-645-2201

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	12/08/2008

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