Provider Demographics
NPI:1316970023
Name:VENJARA, IQBAL (OPHTHALMIC DISPENSER)
Entity type:Individual
Prefix:
First Name:IQBAL
Middle Name:
Last Name:VENJARA
Suffix:
Gender:M
Credentials:OPHTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9508 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4811
Mailing Address - Country:US
Mailing Address - Phone:718-444-3126
Mailing Address - Fax:718-444-3126
Practice Address - Street 1:9508 AVENUE L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4811
Practice Address - Country:US
Practice Address - Phone:718-444-3126
Practice Address - Fax:718-444-3126
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005083-1156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0764750001Medicare NSC