Provider Demographics
NPI:1972564193
Name:MENASSE, MICHAEL ROBERT (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:MENASSE
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 1:637 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-5434
Mailing Address - Country:US
Mailing Address - Phone:718-499-4260
Mailing Address - Fax:718-499-6007
Practice Address - Street 1:637 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-5434
Practice Address - Country:US
Practice Address - Phone:718-499-4260
Practice Address - Fax:718-499-6007
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC0053311156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01050339Medicaid
NY01050339Medicaid
NY0147870001Medicare NSC