MEDICARE: OPTOMETRIC PHYSICIANS OF LONG BRANCH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	27OA00542500	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780790097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTOMETRIC PHYSICIANS OF LONG BRANCH LLC

Provider Business Mailing Address
First Line	:	444 OCEAN BLVD
Second Line	:	URSULA PLAZA
City	:	LONG BRANCH
State	:	NJ
Zip	:	07740-5651
Country	:	US
Telephone Number	:	732-870-0600
Fax Number	:	732-870-0020

Provider Business Practice Location Address
First Line	:	444 OCEAN BLVD
Second Line	:	URSULA PLAZA
City	:	LONG BRANCH
State	:	NJ
Zip	:	07740-5651
Country	:	US
Telephone Number	:	732-870-0600
Fax Number	:	732-870-0020

Authorized Official
Title or Position	:	OWNER
Name	:	MR. TODD H GERSHENOW
Credential	:	O.D.
Telephone Number	:	732-671-7300

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/02/2009

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