Provider Demographics
NPI:1689731721
Name:MGM OPTICIANS INC
Entity Type:Organization
Organization Name:MGM OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:GOOTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-536-0460
Mailing Address - Street 1:345 UNION HILL RD
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-1875
Mailing Address - Country:US
Mailing Address - Phone:732-536-0460
Mailing Address - Fax:732-536-0421
Practice Address - Street 1:345 UNION HILL RD
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-1875
Practice Address - Country:US
Practice Address - Phone:732-536-0460
Practice Address - Fax:732-536-0421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-01
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00151100156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0514250001Medicare NSC