MEDICARE: KJ OPTOMETRY PLLC

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

General Provider Information

NPI Number	:	1588252423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KJ OPTOMETRY PLLC

Provider Business Mailing Address
First Line	:	2313 65TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-4045
Country	:	US
Telephone Number	:	718-975-4824
Fax Number	:

Provider Business Practice Location Address
First Line	:	1803 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3515
Country	:	US
Telephone Number	:	718-975-4824
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MIKHAIL ODESSKIY
Credential	:
Telephone Number	:	718-975-4824

Provider Enumeration Date	:	01/06/2021
Last Update Date	:	01/06/2021

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