Provider Demographics
NPI:1992881486
Name:MARDER, IRA E (OPTICIAN)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:E
Last Name:MARDER
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 1:155 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-2150
Mailing Address - Country:US
Mailing Address - Phone:631-567-2504
Mailing Address - Fax:
Practice Address - Street 1:1033 GREEN ACRES MALL
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1531
Practice Address - Country:US
Practice Address - Phone:516-825-8990
Practice Address - Fax:516-872-2702
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3751156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01016646Medicaid
NY01016646Medicaid