Provider Demographics
NPI:1679634208
Name:BERGEN OPTOMETRY GROUP, PA
Entity Type:Organization
Organization Name:BERGEN OPTOMETRY GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:EHRENWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:201-342-4255
Mailing Address - Street 1:348 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5803
Mailing Address - Country:US
Mailing Address - Phone:201-342-4255
Mailing Address - Fax:201-487-4886
Practice Address - Street 1:348 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5803
Practice Address - Country:US
Practice Address - Phone:201-342-4255
Practice Address - Fax:201-487-4886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27TO00046002152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ295909Medicaid
NJ295909Medicaid