Provider Demographics
NPI:1003595422
Name:PHILLIPS, NIA (OD)
Entity type:Individual
Prefix:
First Name:NIA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 MOUNTAIN AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-2736
Mailing Address - Country:US
Mailing Address - Phone:908-458-8333
Mailing Address - Fax:908-967-5488
Practice Address - Street 1:385 PROSPECT AVE STE 300
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2570
Practice Address - Country:US
Practice Address - Phone:201-342-5191
Practice Address - Fax:201-487-0026
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00731000152W00000X
PAOEG004049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist