Provider Demographics
NPI:1316121494
Name:USTAYEV, ROBERT (OPT)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:USTAYEV
Suffix:
Gender:M
Credentials:OPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 GREENPOINT AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-3004
Mailing Address - Country:US
Mailing Address - Phone:718-391-0003
Mailing Address - Fax:718-391-0003
Practice Address - Street 1:4309 GREENPOINT AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-3004
Practice Address - Country:US
Practice Address - Phone:718-391-0003
Practice Address - Fax:718-391-0003
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-25
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008747-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician