Basic Information
| Provider Information | |||||||||
| NPI: | 1336321728 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORONA OPTOMETRY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103-06 ROOSEVELT AVENUE | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184241333 | ||||||||
| FaxNumber: | 7184241330 | ||||||||
| Practice Location | |||||||||
| Address1: | 103-06 ROOSEVELT AVENUE | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184241333 | ||||||||
| FaxNumber: | 7184241330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | HOURIZADEH | ||||||||
| AuthorizedOfficialFirstName: | PEZHMAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7182421333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TUV007045 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 02811172 | 05 | NY | MEDICAID |