Provider Demographics
NPI:1568635852
Name:RETINA VITREOUS CONSULTANTS OF NEW JERSEY, LLC
Entity Type:Organization
Organization Name:RETINA VITREOUS CONSULTANTS OF NEW JERSEY, LLC
Other - Org Name:BERNARD J. FOWLER, M.D., F.A.C.S.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-871-3414
Mailing Address - Street 1:216 ENGLE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2444
Mailing Address - Country:US
Mailing Address - Phone:201-871-3414
Mailing Address - Fax:201-871-4830
Practice Address - Street 1:216 ENGLE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2444
Practice Address - Country:US
Practice Address - Phone:201-871-3414
Practice Address - Fax:201-871-4830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX ID
NJ128935Medicare PIN