Provider Demographics
NPI:1114191715
Name:NORTHWEST OPTOMETRY GROUP, P.A.
Entity Type:Organization
Organization Name:NORTHWEST OPTOMETRY GROUP, P.A.
Other - Org Name:BLAIRSTOWN EYE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P.
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:908-832-9211
Mailing Address - Street 1:174 STATE ROUTE 94
Mailing Address - Street 2:
Mailing Address - City:BLAIRSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07825-2115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:174 STATE ROUTE 94
Practice Address - Street 2:
Practice Address - City:BLAIRSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07825-2115
Practice Address - Country:US
Practice Address - Phone:908-362-8257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST OPTOMETRY GROUP, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-15
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0307720003Medicare NSC