Provider Demographics
NPI:1124118922
Name:UNIVERSAL OPTOMETRY P.C.
Entity type:Organization
Organization Name:UNIVERSAL OPTOMETRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-896-1934
Mailing Address - Street 1:7259 KISSENA BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2723
Mailing Address - Country:US
Mailing Address - Phone:718-896-1934
Mailing Address - Fax:
Practice Address - Street 1:7259 KISSENA BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-2723
Practice Address - Country:US
Practice Address - Phone:718-896-1934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV 006926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02825363Medicaid
NY02825363Medicaid