Provider Demographics
NPI:1508802513
Name:RAEVA, NATALIA (OD)
Entity Type:Individual
Prefix:DR
First Name:NATALIA
Middle Name:
Last Name:RAEVA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 RIVER RD
Mailing Address - Street 2:16D
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1456
Mailing Address - Country:US
Mailing Address - Phone:201-414-6490
Mailing Address - Fax:201-886-2160
Practice Address - Street 1:32-01 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-4616
Practice Address - Country:US
Practice Address - Phone:201-414-6490
Practice Address - Fax:201-886-2160
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27TO00116402152W00000X
NYT006396152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1084777OtherAETNA PROVIDER NUMBER
NJ3947164OtherCIGNA PROVIDER NUMBER
NJ3K2198OtherHEALTHNET PROVIDER NUMBER
NJNPIOtherQUALCARE
NJ219230OtherEYEMED PROVIDER NUMBER
NJ29840OtherSPECTERA PROVIDER NUMBER
NJ52387OtherDAVIS VISION PROVIDER NUM
NJ0032875Medicaid
NY02530129Medicaid
NJ52387OtherDAVIS VISION PROVIDER NUM
NJ079744Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NY02530129Medicaid