Healthcare Provider Details

I. General information

NPI: 1902678220
Provider Name (Legal Business Name): ETHAN SKYLAR VOGEL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 BROAD ST STE 110
BLOOMFIELD NJ
07003-3039
US

IV. Provider business mailing address

1455 BROAD ST STE 110
BLOOMFIELD NJ
07003-3039
US

V. Phone/Fax

Practice location:
  • Phone: 973-779-0808
  • Fax: 973-471-1929
Mailing address:
  • Phone: 973-779-0808
  • Fax: 973-471-1929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number27OA00725300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: