Provider Demographics
NPI:1871699843
Name:JACOB GALPER
Entity type:Organization
Organization Name:JACOB GALPER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:GALPER
Authorized Official - Suffix:
Authorized Official - Credentials:LO
Authorized Official - Phone:860-667-0921
Mailing Address - Street 1:2311 BERLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3206
Mailing Address - Country:US
Mailing Address - Phone:860-667-0921
Mailing Address - Fax:860-665-7550
Practice Address - Street 1:2311 BERLIN TPKE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-3206
Practice Address - Country:US
Practice Address - Phone:860-667-0921
Practice Address - Fax:860-665-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001119332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004036984Medicaid
CT112340OtherEYEMED VISION CARE
CT200001119CT01OtherANTHEM
CT112340OtherEYEMED VISION CARE