Provider Demographics
NPI:1023615564
Name:MULLOKANDOVA, JULIETTA (OPTHALMIC DISPENSER)
Entity type:Individual
Prefix:
First Name:JULIETTA
Middle Name:
Last Name:MULLOKANDOVA
Suffix:
Gender:F
Credentials:OPTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10540 62ND RD APT 1M
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1119
Mailing Address - Country:US
Mailing Address - Phone:646-920-0062
Mailing Address - Fax:917-473-6697
Practice Address - Street 1:2445 ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-6003
Practice Address - Country:US
Practice Address - Phone:917-473-6699
Practice Address - Fax:917-473-6697
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0997-01156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician