Provider Demographics
NPI:1124074471
Name:EYESITE VISION II
Entity type:Organization
Organization Name:EYESITE VISION II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:ENORENSE
Authorized Official - Last Name:IDEHEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-235-7900
Mailing Address - Street 1:1125 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-3310
Mailing Address - Country:US
Mailing Address - Phone:718-235-7900
Mailing Address - Fax:718-235-7909
Practice Address - Street 1:1125 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-3310
Practice Address - Country:US
Practice Address - Phone:718-235-7900
Practice Address - Fax:718-235-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT006065152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02579106Medicaid