MEDICARE: INNOVISION OPTOMETRY NJ PC

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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1922608728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVISION OPTOMETRY NJ PC

Provider Business Mailing Address
First Line	:	310 WINDSOR HWY
Second Line	:
City	:	NEW WINDSOR
State	:	NY
Zip	:	12553-6908
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	63 W PLEASANT AVE
Second Line	:
City	:	MAYWOOD
State	:	NJ
Zip	:	07607-1334
Country	:	US
Telephone Number	:	201-845-4700
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KETAN KUTLERYWALA
Credential	:
Telephone Number	:	845-541-9689

Provider Enumeration Date	:	10/29/2020
Last Update Date	:	11/03/2020

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