Healthcare Provider Details

I. General information

NPI: 1346377520
Provider Name (Legal Business Name): I. DAVID NESTOROWICZ L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4345 US RT 9 NORTH
FREEHOLD NJ
07728
US

IV. Provider business mailing address

4345 US RT 9 NORTH
FREEHOLD NJ
07728
US

V. Phone/Fax

Practice location:
  • Phone: 732-431-1004
  • Fax: 732-431-1006
Mailing address:
  • Phone: 732-431-1004
  • Fax: 732-431-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number270A00607300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: IGOR NESTOROWICZ
Title or Position: PRESIDENT
Credential: O.D.
Phone: 732-431-1004