MEDICARE: MIKE GHOSSN OD

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	004407	NY

General Provider Information

NPI Number	:	1285768036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKE GHOSSN OD

Provider Business Mailing Address
First Line	:	20 GLEASON DR
Second Line	:
City	:	DIX HILLS
State	:	NY
Zip	:	11746-6535
Country	:	US
Telephone Number	:	631-242-9534
Fax Number	:	516-731-4900

Provider Business Practice Location Address
First Line	:	3270 HEMPSTEAD TPKE
Second Line	:
City	:	LEVITTOWN
State	:	NY
Zip	:	11756-1345
Country	:	US
Telephone Number	:	516-731-5050
Fax Number	:	516-731-4900

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	12/11/2007

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