Provider Demographics
NPI:1851528772
Name:DAVID IOSEBASHVILI PC
Entity Type:Organization
Organization Name:DAVID IOSEBASHVILI PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:IOSEBASHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:973-589-7369
Mailing Address - Street 1:1315 ANDERSON AVE UNITE #28
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024
Mailing Address - Country:US
Mailing Address - Phone:973-589-7369
Mailing Address - Fax:973-589-2891
Practice Address - Street 1:106 FERRY STR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105
Practice Address - Country:US
Practice Address - Phone:973-589-7369
Practice Address - Fax:973-589-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty