Provider Demographics
NPI:1083780175
Name:JG OPTICAL INC.
Entity Type:Organization
Organization Name:JG OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-743-1353
Mailing Address - Street 1:108 BROUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3989
Mailing Address - Country:US
Mailing Address - Phone:973-743-1353
Mailing Address - Fax:973-743-6577
Practice Address - Street 1:108 BROUGHTON AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:973-743-1353
Practice Address - Fax:973-743-6577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTD3340156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ300090701Medicaid