Provider Demographics
NPI:1871776450
Name:JOHN A. FACCHIN, O.D.
Entity type:Organization
Organization Name:JOHN A. FACCHIN, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FACCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-798-2635
Mailing Address - Street 1:1 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5718
Mailing Address - Country:US
Mailing Address - Phone:516-220-7787
Mailing Address - Fax:
Practice Address - Street 1:111 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-4905
Practice Address - Country:US
Practice Address - Phone:516-798-2635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0978400001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01474419Medicaid
NYC2A471Medicare PIN
NY0978400001Medicare NSC
NY01474419Medicaid