MEDICARE: DR. BERNABE A. LORET DE MOLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	MA30301	NJ

General Provider Information

NPI Number	:	1508867169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERNABE A. LORET DE MOLA M.D.

Provider Business Mailing Address
First Line	:	433 60TH ST
Second Line	:
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093-2211
Country	:	US
Telephone Number	:	201-861-5333
Fax Number	:	201-869-6091

Provider Business Practice Location Address
First Line	:	433 60TH ST
Second Line	:
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093-2211
Country	:	US
Telephone Number	:	201-861-5333
Fax Number	:	201-869-6091

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	07/08/2007

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