Provider Demographics
NPI:1851339840
Name:EDISON OPHTHALMOLOGY ASSOCIATES L.L.C.
Entity Type:Organization
Organization Name:EDISON OPHTHALMOLOGY ASSOCIATES L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-822-0070
Mailing Address - Street 1:2177 OAK TREE RD
Mailing Address - Street 2:#203
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1082
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2177 OAK TREE RD
Practice Address - Street 2:#203
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1082
Practice Address - Country:US
Practice Address - Phone:908-822-0070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07540000207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2334336000OtherAMERIHEALTH HMO ID