Provider Demographics
NPI:1073718177
Name:CERAGNO, ROBERT FRANK (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:FRANK
Last Name:CERAGNO
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7733 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4966
Mailing Address - Country:US
Mailing Address - Phone:201-868-0768
Mailing Address - Fax:201-868-2960
Practice Address - Street 1:7733 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4966
Practice Address - Country:US
Practice Address - Phone:201-868-0768
Practice Address - Fax:201-868-2960
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ 1720156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0024074Medicaid
NJ0024074Medicaid