Provider Demographics
NPI:1942936778
Name:HARTONO, JACQUELINE (OD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HARTONO
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 1:725 METROPOLITAN AVE APT 4B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-3875
Mailing Address - Country:US
Mailing Address - Phone:805-990-4192
Mailing Address - Fax:
Practice Address - Street 1:33 W 42ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-8005
Practice Address - Country:US
Practice Address - Phone:212-938-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009616152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist