Provider Demographics
NPI:1902091523
Name:ADVANTAGE OPTICAL
Entity Type:Organization
Organization Name:ADVANTAGE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUIDA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-679-5866
Mailing Address - Street 1:542 JERUSALEM AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-1829
Mailing Address - Country:US
Mailing Address - Phone:516-679-5866
Mailing Address - Fax:516-679-5869
Practice Address - Street 1:542 JERUSALEM AVE
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-1829
Practice Address - Country:US
Practice Address - Phone:516-679-5866
Practice Address - Fax:516-679-5869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2022-07-29
Deactivation Date:2020-03-11
Deactivation Code:
Reactivation Date:2022-07-29
Provider Licenses
StateLicense IDTaxonomies
NYVUT005946-1332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02439985Medicaid
NYU98410Medicare UPIN
NYC308D1Medicare PIN
NY5017520001Medicare NSC