Provider Demographics
NPI:1912384652
Name:DP 17 OPTOMETRIC ASSOCIATES
Entity Type:Organization
Organization Name:DP 17 OPTOMETRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:201-599-1102
Mailing Address - Street 1:494 N RTE 17
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3012
Mailing Address - Country:US
Mailing Address - Phone:201-599-1102
Mailing Address - Fax:201-599-1202
Practice Address - Street 1:494 N RTE 17
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3012
Practice Address - Country:US
Practice Address - Phone:201-599-1102
Practice Address - Fax:201-599-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27040552800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty