Provider Demographics
NPI:1902219033
Name:MIKITCHENKO, TANYA (OD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MIKITCHENKO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328B SPARTA AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1167
Mailing Address - Country:US
Mailing Address - Phone:973-604-2020
Mailing Address - Fax:
Practice Address - Street 1:328B SPARTA AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1167
Practice Address - Country:US
Practice Address - Phone:973-604-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008131152W00000X
NJ27OA00710300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist