Provider Demographics
NPI:1518098524
Name:FRUCHTMAN, JERROLD (OD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:
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 1:39 BROWNING RD
Mailing Address - Street 2:
Mailing Address - City:SHORT HILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07078-1115
Mailing Address - Country:US
Mailing Address - Phone:973-912-7219
Mailing Address - Fax:
Practice Address - Street 1:256 COLUMBIA TPKE
Practice Address - Street 2:STE 211
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1231
Practice Address - Country:US
Practice Address - Phone:973-301-0400
Practice Address - Fax:973-301-8928
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU20175Medicare UPIN
NJ529410Medicare ID - Type Unspecified