Provider Demographics
NPI:1356491930
Name:BETHPAGE OPTICAL, LLC
Entity type:Organization
Organization Name:BETHPAGE OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAVULUNOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-433-2015
Mailing Address - Street 1:582 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-2702
Mailing Address - Country:US
Mailing Address - Phone:516-433-2015
Mailing Address - Fax:516-433-2017
Practice Address - Street 1:582 STEWART AVE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-2702
Practice Address - Country:US
Practice Address - Phone:516-433-2015
Practice Address - Fax:516-433-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007319-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY15602OtherSPECTERA
NY919607OtherBLOCK VISION
NYNY0543OtherEYEMED
NY859OtherVISION SCREENING