1437369667 NPI number — FRED A PODBIELAK OPTHALMIC DISPENSER

Table of content: FRED A PODBIELAK OPTHALMIC DISPENSER (NPI 1437369667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437369667 NPI number — FRED A PODBIELAK OPTHALMIC DISPENSER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PODBIELAK
Provider First Name:
FRED
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OPTHALMIC DISPENSER
Provider Gender Code:
M

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:
1437369667
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 NEWARK AVE
Provider Second Line Business Mailing Address:
STE 204
Provider Business Mailing Address City Name:
ELIZABETH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07208-3550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-355-2774
Provider Business Mailing Address Fax Number:
908-355-1185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 NEWARK AVE
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
ELIZABETH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07208-3550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-355-2774
Provider Business Practice Location Address Fax Number:
908-355-1185
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  TD-2296 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6777104 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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