Provider Demographics
NPI:1699956037
Name:BALDWIN OPTOMETRY PC
Entity type:Organization
Organization Name:BALDWIN OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELUCA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-223-0528
Mailing Address - Street 1:2429 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3219
Mailing Address - Country:US
Mailing Address - Phone:516-223-0528
Mailing Address - Fax:516-223-0730
Practice Address - Street 1:2429 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3219
Practice Address - Country:US
Practice Address - Phone:516-223-0528
Practice Address - Fax:516-223-0730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005434152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400042587OtherMEDICARE MEMBER- CHARLES J DELUCA OD- PTAN
NY03064115Medicaid
NYA100042581OtherMEDICARE GROUP PTAN
NYA100042581OtherMEDICARE GROUP PTAN