Provider Demographics
NPI:1609885623
Name:OPTOMETRIC PHYSICIANS OF HAZLET LLC
Entity type:Organization
Organization Name:OPTOMETRIC PHYSICIANS OF HAZLET LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:H
Authorized Official - Last Name:GERSHENOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:732-671-7300
Mailing Address - Street 1:3013 STATE ROUTE 35
Mailing Address - Street 2:HAZLET PLAZA
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-1526
Mailing Address - Country:US
Mailing Address - Phone:732-739-4000
Mailing Address - Fax:732-739-4002
Practice Address - Street 1:3013 STATE ROUTE 35
Practice Address - Street 2:HAZLET PLAZA
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-1526
Practice Address - Country:US
Practice Address - Phone:732-739-4000
Practice Address - Fax:732-739-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00300100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3121402Medicaid
NJ3121402Medicaid
NJ6104890001Medicare NSC