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NPI Code Detail

MEDICARE: MEDPLAZA OPTICAL INC

MEDICARE: MEDPLAZA OPTICAL 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
1152W00000XOptometristVUT006567NY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1568405629
Entity Type Code : Organization
Provider Name (Legal Business Name) : MEDPLAZA OPTICAL INC
Provider Business Mailing Address
First Line : 3065 BRIGHTON 14TH ST
Second Line :
City : BROOKLYN
State : NY
Zip : 11235-5501
Country : US
Telephone Number : 718-332-5047
Fax Number :
Provider Business Practice Location Address
First Line : 3065 BRIGHTON 14TH ST
Second Line :
City : BROOKLYN
State : NY
Zip : 11235-5501
Country : US
Telephone Number : 718-332-5047
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : ALEXANDER KOVBASYUK
Credential :
Telephone Number : 718-332-5047
Provider Enumeration Date : 06/14/2006
Last Update Date : 11/23/2007

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