Provider Demographics
NPI:1679240329
Name:RAITHATHA, SUNNY MUKUL
Entity Type:Individual
Prefix:DR
First Name:SUNNY
Middle Name:MUKUL
Last Name:RAITHATHA
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:SUNNY
Other - Middle Name:
Other - Last Name:RAI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:59 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-1813
Mailing Address - Country:US
Mailing Address - Phone:201-724-2227
Mailing Address - Fax:
Practice Address - Street 1:461 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-2740
Practice Address - Country:US
Practice Address - Phone:201-420-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-29
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009437152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist