MEDICARE: MDS OPTOMETRY AND OPHTHALMIC DISPENSING 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	:	1851792055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MDS OPTOMETRY AND OPHTHALMIC DISPENSING PLLC

Provider Business Mailing Address
First Line	:	1566A 1ST AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10028-4004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1566A 1ST AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10028-4004
Country	:	US
Telephone Number	:	212-217-1600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHEAL KAKZANOV
Credential	:
Telephone Number	:	212-217-1600

Provider Enumeration Date	:	09/08/2014
Last Update Date	:	09/12/2014

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