MEDICARE: OPTICAL IDEAS, INC.

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	152W00000X	Optometrist	TUV005342-1	NY

General Provider Information

NPI Number	:	1215153937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL IDEAS, INC.

Provider Business Mailing Address
First Line	:	2168 WHITE PLAINS RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10462-1406
Country	:	US
Telephone Number	:	718-931-0500
Fax Number	:	718-430-9793

Provider Business Practice Location Address
First Line	:	2168 WHITE PLAINS RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10462-1406
Country	:	US
Telephone Number	:	718-931-0500
Fax Number	:	718-430-9793

Authorized Official
Title or Position	:	OWNER
Name	:	MR. STAN ROTH
Credential	:
Telephone Number	:	718-931-0500

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	08/22/2020

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Directions to “OPTICAL IDEAS, INC. ” Practice Location

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