=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184038150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NINA BAJAJ O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2014
-----------------------------------------------------
Last Update Date | 01/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 279 FERRY ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07105-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-344-2212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 279 FERRY ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07105-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-344-2212
-----------------------------------------------------
Fax | 973-344-4651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 008124
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 27OA00684000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------