Provider Demographics
NPI:1972775583
Name:SOUTH OCEAN OPHTHALMOLOGY PC
Entity type:Organization
Organization Name:SOUTH OCEAN OPHTHALMOLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:GARCIA
Authorized Official - Last Name:LESSING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-289-0001
Mailing Address - Street 1:260 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4886
Mailing Address - Country:US
Mailing Address - Phone:631-289-0001
Mailing Address - Fax:631-758-2958
Practice Address - Street 1:260 PATCHOGUE YAPHANK RD
Practice Address - Street 2:SUITE A
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4886
Practice Address - Country:US
Practice Address - Phone:631-289-0001
Practice Address - Fax:631-758-2958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204125207W00000X
NY114521207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02075203Medicaid
NY00430722Medicaid
NY02075203Medicaid
NY40Z23XWQV1Medicare PIN
G90619Medicare UPIN
NYWXWQV1Medicare PIN