Provider Demographics
NPI:1871725754
Name:MAZ OPTICAL, INC
Entity type:Organization
Organization Name:MAZ OPTICAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEPPERS
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:631-471-0600
Mailing Address - Street 1:971 MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1609
Mailing Address - Country:US
Mailing Address - Phone:631-471-0600
Mailing Address - Fax:631-883-3365
Practice Address - Street 1:971 MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1609
Practice Address - Country:US
Practice Address - Phone:631-471-0600
Practice Address - Fax:631-883-3365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
NY5877-1332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU19870Medicare UPIN
NYV07405Medicare UPIN