Provider Demographics
NPI:1497397947
Name:NISSINOFF, JORDAN (OD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:NISSINOFF
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 1:2 12TH ST APT PH07
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-6785
Mailing Address - Country:US
Mailing Address - Phone:321-537-9976
Mailing Address - Fax:
Practice Address - Street 1:112 EISENHOWER PKWY STE 44
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4900
Practice Address - Country:US
Practice Address - Phone:973-535-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00692800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist