MEDICARE: WITZ OPTICAL CORP

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	156FX1800X	Optician	004641	NY
2	156FX1800X	Optician	006692	NY
3	152W00000X	Optometrist	TU003858	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6500308	OTHER	NY	GHI
2	76664	OTHER	NY	AETNA

General Provider Information

NPI Number	:	1427007053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WITZ OPTICAL CORP

Provider Business Mailing Address
First Line	:	2303 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3918
Country	:	US
Telephone Number	:	718-982-9602
Fax Number	:	718-982-9607

Provider Business Practice Location Address
First Line	:	2303 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3918
Country	:	US
Telephone Number	:	718-982-9602
Fax Number	:	718-982-9607

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NEIL COOPER
Credential	:	O.D.
Telephone Number	:	718-982-9602

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	01/05/2008

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Directions to “WITZ OPTICAL CORP ” Practice Location

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