Provider Demographics
NPI:1831100031
Name:IOSEBASHVILI, DAVID (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:IOSEBASHVILI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766 BLOOMFIELD AVE.
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006
Mailing Address - Country:US
Mailing Address - Phone:973-882-1967
Mailing Address - Fax:973-882-5553
Practice Address - Street 1:766 BLOOMFIELD AVE.
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006
Practice Address - Country:US
Practice Address - Phone:973-882-1967
Practice Address - Fax:973-882-5553
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA 00592800152W00000X
NYTUV 006788152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3973690OtherAETNA ID NUMBER
NJ3973690OtherAETNA ID NUMBER
NJV02727Medicare UPIN