Provider Demographics
NPI:1316125594
Name:BH OPTICAL OF QUEENS, INC.
Entity type:Organization
Organization Name:BH OPTICAL OF QUEENS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:USTAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:OPT
Authorized Official - Phone:718-391-0003
Mailing Address - Street 1:4309 GREENPOINT AVENUE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-2605
Mailing Address - Country:US
Mailing Address - Phone:718-391-0003
Mailing Address - Fax:718-391-0003
Practice Address - Street 1:4309 GREENPOINT AVENUE
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-09
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008747-1156FX1800X
NYT-003792152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02936698Medicaid