MEDICARE: OPTICAL WAREHOUSE OUTLET OF WILLIAMSBURG

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	T006545	NY

General Provider Information

NPI Number	:	1396832515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL WAREHOUSE OUTLET OF WILLIAMSBURG

Provider Business Mailing Address
First Line	:	366 GRAHAM AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11211-2410
Country	:	US
Telephone Number	:	718-388-3300
Fax Number	:	718-388-3328

Provider Business Practice Location Address
First Line	:	366 GRAHAM AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11211-2410
Country	:	US
Telephone Number	:	718-388-3300
Fax Number	:	718-388-3328

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	JANE KUTSOWSKY
Credential	:	O.D.
Telephone Number	:	917-674-1989

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	08/22/2020

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