Provider Demographics
NPI:1801853254
Name:NORTHWEST OPTOMETRY GROUP, P.A.
Entity Type:Organization
Organization Name:NORTHWEST OPTOMETRY GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P.
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:908-832-9211
Mailing Address - Street 1:117 SPARTA AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1773
Mailing Address - Country:US
Mailing Address - Phone:973-729-9199
Mailing Address - Fax:973-729-9260
Practice Address - Street 1:117 SPARTA AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1773
Practice Address - Country:US
Practice Address - Phone:973-729-9199
Practice Address - Fax:973-729-9260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ331420102Medicaid
NJ331420106Medicaid
NJ331420104Medicaid
CD9470OtherRAILROAD MEDICARE
NJ331420105Medicaid
NJ331420103Medicaid
0307720001Medicare NSC
0307720002Medicare NSC
NJ331420106Medicaid
NJ331420103Medicaid
NJ331420104Medicaid
NJ331420105Medicaid