Provider Demographics
NPI:1417168832
Name:ICONOPTICAL DBA PEARLE VISION
Entity Type:Organization
Organization Name:ICONOPTICAL DBA PEARLE VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-361-8990
Mailing Address - Street 1:124 RT 10
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869
Mailing Address - Country:US
Mailing Address - Phone:973-361-8990
Mailing Address - Fax:
Practice Address - Street 1:124 RT 10
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869
Practice Address - Country:US
Practice Address - Phone:973-361-8990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========Medicare UPIN