Provider Demographics
NPI:1447292586
Name:IPPOLITO, JOHN MARIO (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARIO
Last Name:IPPOLITO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1107 VALLEY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:STIRLING
Mailing Address - State:NJ
Mailing Address - Zip Code:07980-1524
Mailing Address - Country:US
Mailing Address - Phone:908-580-2555
Mailing Address - Fax:908-580-2544
Practice Address - Street 1:1107 VALLEY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:STIRLING
Practice Address - State:NJ
Practice Address - Zip Code:07980-1524
Practice Address - Country:US
Practice Address - Phone:908-580-2555
Practice Address - Fax:908-580-2544
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-02-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ27OA00542600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU63477Medicare UPIN