Provider Demographics
NPI:1790709384
Name:RAITHATHA, PARAG CHAMPKLAL (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:PARAG
Middle Name:CHAMPKLAL
Last Name:RAITHATHA
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091B SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-2408
Mailing Address - Country:US
Mailing Address - Phone:973-416-6664
Mailing Address - Fax:973-424-0072
Practice Address - Street 1:1091B SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-2408
Practice Address - Country:US
Practice Address - Phone:973-416-6664
Practice Address - Fax:973-424-0072
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTD3405156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0105627Medicaid