Provider Demographics
NPI:1386101632
Name:OPTICAL SHOP OF DEER PARK INC
Entity type:Organization
Organization Name:OPTICAL SHOP OF DEER PARK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:GLADSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-887-8872
Mailing Address - Street 1:415 COMMACK RD STE 2B
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-4508
Mailing Address - Country:US
Mailing Address - Phone:631-392-0711
Mailing Address - Fax:631-392-0752
Practice Address - Street 1:415 COMMACK RD STE 2B
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-4508
Practice Address - Country:US
Practice Address - Phone:631-392-0711
Practice Address - Fax:631-392-0752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-22
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty