Healthcare Provider Details

I. General information

NPI: 1326087156
Provider Name (Legal Business Name): RETINA VITREAUS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 GALLOPING HILL RD
KENILWORTH NJ
07033-1303
US

IV. Provider business mailing address

1700 GALLOPING HILL RD
KENILWORTH NJ
07033-1303
US

V. Phone/Fax

Practice location:
  • Phone: 908-488-8333
  • Fax: 908-458-8339
Mailing address:
  • Phone: 908-488-8333
  • Fax: 908-458-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD J LUDWIG III
Title or Position: PRACTICE ADMINISTRATOR
Credential: FACMPE
Phone: 732-568-1246