=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821471657
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALAY PANSHERIA O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2015
-----------------------------------------------------
Last Update Date | 12/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4-14 SADDLE RIVER RD STE 202
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410-5624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-797-2747
-----------------------------------------------------
Fax | 201-254-9767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4-14 SADDLE RIVER RD STE 202
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410-5624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-797-2747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT-OPT-LIC-4556
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 27OA00659800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0618003065
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3738-35
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT.0003740
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3849
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------