Provider Demographics
NPI:1841425840
Name:SANTAMARIA EYE CENTER P A
Entity Type:Organization
Organization Name:SANTAMARIA EYE CENTER P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MENCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DISLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-826-5159
Mailing Address - Street 1:100 MENLO PARK DRIVE
Mailing Address - Street 2:SUITE 408
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837
Mailing Address - Country:US
Mailing Address - Phone:732-826-5159
Mailing Address - Fax:732-826-2107
Practice Address - Street 1:100 MENLO PARK DRIVE
Practice Address - Street 2:SUITE 408
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837
Practice Address - Country:US
Practice Address - Phone:732-826-5159
Practice Address - Fax:732-826-2107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA034125207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1235010002Medicare NSC
NJ527710Medicare PIN