Provider Demographics
NPI:1417920042
Name:MIRKIN VISION CARE PC
Entity type:Organization
Organization Name:MIRKIN VISION CARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:PROF
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MIRKIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-634-0005
Mailing Address - Street 1:253 BEACH 116TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2102
Mailing Address - Country:US
Mailing Address - Phone:718-634-0005
Mailing Address - Fax:718-474-2003
Practice Address - Street 1:253 BEACH 116TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2102
Practice Address - Country:US
Practice Address - Phone:718-634-0005
Practice Address - Fax:718-474-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004688152W00000X
NYVUT004688332BC3200X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01126778Medicaid
34931Medicare PIN
NYT92613Medicare UPIN
NY01126778Medicaid