Provider Demographics
NPI:1447200241
Name:FRUCHTMAN, WILLIAM CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:CHARLES
Last Name:FRUCHTMAN
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 1:196 PATERSON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07073-1841
Mailing Address - Country:US
Mailing Address - Phone:201-728-9222
Mailing Address - Fax:201-728-9229
Practice Address - Street 1:196 PATERSON AVE
Practice Address - Street 2:
Practice Address - City:EAST RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07073-1841
Practice Address - Country:US
Practice Address - Phone:201-728-9222
Practice Address - Fax:201-728-9229
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00514400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4590902Medicaid
NJ4590902Medicaid
NJDN5374Medicare PIN
NJ698641VHAMedicare PIN