Healthcare Provider Details

I. General information

NPI: 1609124296
Provider Name (Legal Business Name): MICHAEL THOMAS MONTENARE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 CEDAR HILL AVE STE H
WYCKOFF NJ
07481-2150
US

IV. Provider business mailing address

67 COTTAGE ST FL 1
MIDLAND PARK NJ
07432-1953
US

V. Phone/Fax

Practice location:
  • Phone: 631-455-7123
  • Fax:
Mailing address:
  • Phone: 631-455-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00641300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number27OA00641300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: