Healthcare Provider Details

I. General information

NPI: 1790441129
Provider Name (Legal Business Name): MR. ANTHONY MONGIELLO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E 2ND ST SUITE B
PLAINFIELD NJ
07060-1214
US

IV. Provider business mailing address

160 E 2ND ST SUITE B
PLAINFIELD NJ
07060-1214
US

V. Phone/Fax

Practice location:
  • Phone: 732-804-5756
  • Fax:
Mailing address:
  • Phone: 732-804-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberTD1382
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier160244
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: