Healthcare Provider Details

I. General information

NPI: 1922608728
Provider Name (Legal Business Name): INNOVISION OPTOMETRY NJ PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 W PLEASANT AVE
MAYWOOD NJ
07607-1334
US

IV. Provider business mailing address

310 WINDSOR HWY
NEW WINDSOR NY
12553-6908
US

V. Phone/Fax

Practice location:
  • Phone: 201-845-4700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. KETAN KUTLERYWALA
Title or Position: PRESIDENT
Credential:
Phone: 845-541-9689