Provider Demographics
NPI:1184643843
Name:MERMELSTEIN, JACK SOL (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:SOL
Last Name:MERMELSTEIN
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 1:4-14 SADDLE RIVER RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5632
Mailing Address - Country:US
Mailing Address - Phone:201-797-2747
Mailing Address - Fax:201-797-5809
Practice Address - Street 1:4-14 SADDLE RIVER RD
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-5632
Practice Address - Country:US
Practice Address - Phone:201-797-2747
Practice Address - Fax:201-797-5809
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3650152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0683302Medicaid
NJU26851Medicare UPIN
NJ0683302Medicaid