Provider Demographics
NPI:1760835375
Name:EZ.MD.OPTICAL LLC
Entity Type:Organization
Organization Name:EZ.MD.OPTICAL LLC
Other - Org Name:EZ MD OPTICAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:LIC OPHTHALMIC DISPENSER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROMERO
Authorized Official - Suffix:SR
Authorized Official - Credentials:31TD00351400
Authorized Official - Phone:201-628-1465
Mailing Address - Street 1:3196 KENNEDY BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-2468
Mailing Address - Country:US
Mailing Address - Phone:201-628-1465
Mailing Address - Fax:
Practice Address - Street 1:3196 KENNEDY BLVD STE 2
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-2468
Practice Address - Country:US
Practice Address - Phone:201-628-1465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EZ MD OPTICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00351400302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0304026Medicaid