Provider Demographics
NPI:1386630150
Name:MALAT, GLENN JAY (OD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:JAY
Last Name:MALAT
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 1:18 RUBINO RD
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-8000
Mailing Address - Country:US
Mailing Address - Phone:973-276-9693
Mailing Address - Fax:973-226-3033
Practice Address - Street 1:775 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-6701
Practice Address - Country:US
Practice Address - Phone:973-226-3031
Practice Address - Fax:973-226-3033
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00530101152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ480551OtherAETNA
NJ2263858OtherUNITED HEALTHCARE
NJP2664631OtherOXFORD
NJ2K4029OtherHEALTH NET
NJ2263858OtherUNITED HEALTHCARE
NJU89861Medicare UPIN