Provider Demographics
NPI:1598998239
Name:GENDY, NIVAN PHILLIPS (OD)
Entity Type:Individual
Prefix:DR
First Name:NIVAN
Middle Name:PHILLIPS
Last Name:GENDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NIVAN
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:290 STATE ROUTE 18
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-1995
Mailing Address - Country:US
Mailing Address - Phone:732-387-1060
Mailing Address - Fax:
Practice Address - Street 1:290 STATE ROUTE 18
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-1995
Practice Address - Country:US
Practice Address - Phone:732-387-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00621300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ27OA00621300OtherNJ STATE BOARD OF OPTOMETRY