Provider Demographics
NPI:1164458154
Name:VANDERYAJT, ROBERT RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RICHARD
Last Name:VANDERYAJT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 ROUTE 23
Mailing Address - Street 2:PLAZA 23
Mailing Address - City:HAMBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07419
Mailing Address - Country:US
Mailing Address - Phone:973-823-0300
Mailing Address - Fax:973-823-0038
Practice Address - Street 1:PLAZA 23
Practice Address - Street 2:225 ROUTE 23
Practice Address - City:HAMBURG
Practice Address - State:NJ
Practice Address - Zip Code:07419
Practice Address - Country:US
Practice Address - Phone:973-823-0300
Practice Address - Fax:973-823-0038
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00441400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1916700Medicaid
NJ521693Medicare PIN
NJ26944Medicare UPIN