Provider Demographics
NPI:1326280512
Name:NORWICH OPHTHALMOLOGY OPTICAL
Entity Type:Organization
Organization Name:NORWICH OPHTHALMOLOGY OPTICAL
Other - Org Name:EYE Q OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-886-0161
Mailing Address - Street 1:179 FLANDERS RD
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-1203
Mailing Address - Country:US
Mailing Address - Phone:860-447-8664
Mailing Address - Fax:860-443-2986
Practice Address - Street 1:179 FLANDERS RD
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-1203
Practice Address - Country:US
Practice Address - Phone:860-447-8664
Practice Address - Fax:860-443-2986
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORWICH OPHTHALMOLOGY OPTICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-02
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00562156FX1800X
CT001058332H00000X
CT000433332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear SupplierGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008002781Medicaid
CT100000433CT03OtherANTHEM BLUE CROSS/SHIELD
CT1299620002Medicare NSC