=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154485464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVINGSTON VITREO RETINAL ASSOCIATES, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 04/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 349 E NORTHFIELD RD SUITE 100
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-716-0123
-----------------------------------------------------
Fax | 973-716-0441
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 349 E NORTHFIELD RD SUITE 100
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-716-0123
-----------------------------------------------------
Fax | 973-716-0441
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | MRS. SARAH SAYLES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-716-0123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 25MA05282200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------