Provider Demographics
NPI:1871761478
Name:DAVIDOFF OPTICAL CENTER CORP.
Entity type:Organization
Organization Name:DAVIDOFF OPTICAL CENTER CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDOV
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:718-275-0955
Mailing Address - Street 1:9309 63RD DR
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2924
Mailing Address - Country:US
Mailing Address - Phone:718-275-0955
Mailing Address - Fax:718-275-3725
Practice Address - Street 1:9309 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2924
Practice Address - Country:US
Practice Address - Phone:718-275-0955
Practice Address - Fax:718-275-3725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6154-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01463767Medicaid
NY0899550001Medicare NSC