Provider Demographics
NPI:1235169830
Name:RAJAN, AVANTI PRAMOD (OD)
Entity Type:Individual
Prefix:
First Name:AVANTI
Middle Name:PRAMOD
Last Name:RAJAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161A WOODBRIDGE CENTER DR.
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095
Mailing Address - Country:US
Mailing Address - Phone:732-855-7950
Mailing Address - Fax:732-726-1735
Practice Address - Street 1:161A WOODBRIDGE CENTER DR.
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095
Practice Address - Country:US
Practice Address - Phone:732-855-7950
Practice Address - Fax:732-726-1735
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00592300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJV02853Medicare UPIN
NJO86702Medicare ID - Type Unspecified