1184996001 NPI number — COSMOS TOTAL OPTOMETRY CARE PLLC

Table of content: (NPI 1184996001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184996001 NPI number — COSMOS TOTAL OPTOMETRY CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COSMOS TOTAL OPTOMETRY CARE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184996001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/27/2015
NPI Reactivation Date:
04/18/2016

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9001 ROOSEVELT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON HEIGHTS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11372-7938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-458-8500
Provider Business Mailing Address Fax Number:
718-424-3366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9001 ROOSEVELT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON HEIGHTS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11372-7938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-458-8500
Provider Business Practice Location Address Fax Number:
718-424-3366
Provider Enumeration Date:
02/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ECONOPOULY
Authorized Official First Name:
JOANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
718-458-8500

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TUV006061 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02220473 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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