Healthcare Provider Details

I. General information

NPI: 1245437755
Provider Name (Legal Business Name): TERRYLEE MAIMONE O.D, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32-01 BROADWAY
FAIR LAWN NJ
07410-4616
US

IV. Provider business mailing address

32-01 BROADWAY
FAIR LAWN NJ
07410-4616
US

V. Phone/Fax

Practice location:
  • Phone: 201-703-2922
  • Fax: 201-791-6626
Mailing address:
  • Phone: 201-703-2922
  • Fax: 201-791-6626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00490500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number27TO00040600
License Number StateNJ

VIII. Authorized Official

Name: DR. TERRYLEE MAIMONE
Title or Position: OWNER
Credential: O.D
Phone: 201-703-2922