Provider Demographics
NPI:1962736371
Name:GUMENIK, VITALY (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:VITALY
Middle Name:
Last Name:GUMENIK
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3903
Mailing Address - Country:US
Mailing Address - Phone:718-975-0642
Mailing Address - Fax:
Practice Address - Street 1:1809 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3903
Practice Address - Country:US
Practice Address - Phone:718-975-0642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008166-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician