Provider Demographics
NPI:1316128143
Name:LONDON, CAROLYN ANNE (OPTICIAN)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANNE
Last Name:LONDON
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2723
Mailing Address - Country:US
Mailing Address - Phone:631-727-3274
Mailing Address - Fax:
Practice Address - Street 1:312 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2723
Practice Address - Country:US
Practice Address - Phone:631-727-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC003396156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0879720001Medicare NSC
NY6078840001Medicare NSC