MEDICARE: OPTICAL WAREHOUSE OUTLET OF WIILIAMSBURGE

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	T6451-1	NY
2	156FX1800X	Optician	007005	NY

General Provider Information

NPI Number	:	1811066111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL WAREHOUSE OUTLET OF WIILIAMSBURGE

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	:

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	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. VADIM KRUZHKOV
Credential	:	OPTICIAN
Telephone Number	:	718-388-3300

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	09/11/2025

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