Provider Demographics
NPI:1346411006
Name:JAMES AVERSA OD PA
Entity Type:Organization
Organization Name:JAMES AVERSA OD PA
Other - Org Name:JAMES AVERSA OD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:AVERSA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:201-288-1109
Mailing Address - Street 1:227 1/2 BLVD
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604-1901
Mailing Address - Country:US
Mailing Address - Phone:201-288-1109
Mailing Address - Fax:201-288-1589
Practice Address - Street 1:227 1/2 BLVD.
Practice Address - Street 2:
Practice Address - City:HASBROUCK HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07604-1901
Practice Address - Country:US
Practice Address - Phone:201-288-1109
Practice Address - Fax:201-288-1589
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JAMES AVERSA OD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00457100152W00000X
NJ27TO00028300332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0674770001Medicare NSC
NJ626422Medicare PIN