Provider Demographics
NPI:1407974629
Name:PEREZ, AUGUSTINE (OPHTHALMIC DISPENSER)
Entity Type:Individual
Prefix:
First Name:AUGUSTINE
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:OPHTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4228
Mailing Address - Country:US
Mailing Address - Phone:973-736-0553
Mailing Address - Fax:073-736-6496
Practice Address - Street 1:235 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-4228
Practice Address - Country:US
Practice Address - Phone:973-736-0553
Practice Address - Fax:073-736-6496
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD2147156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0798440001Medicare ID - Type Unspecified