=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023534690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE GLAUCOMA CARE CENTER OF NEW JERSEY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2017
-----------------------------------------------------
Last Update Date | 01/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 349 E NORTHFIELD RD
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-992-8000
-----------------------------------------------------
Fax | 973-992-8001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 349 E NORTHFIELD RD
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-364-9106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | AMIR COHEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-992-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------