Provider Demographics
NPI:1013319052
Name:LODESPOTO MEDICAL OF NJ LLC
Entity Type:Organization
Organization Name:LODESPOTO MEDICAL OF NJ LLC
Other - Org Name:EYECUITY OF NEW JERSEY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:LODESPOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-335-8909
Mailing Address - Street 1:PO BOX 958
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-0811
Mailing Address - Country:US
Mailing Address - Phone:201-335-8909
Mailing Address - Fax:844-840-7352
Practice Address - Street 1:225 PASSAIC ST
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-6414
Practice Address - Country:US
Practice Address - Phone:201-335-8909
Practice Address - Fax:844-840-7352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA093008002085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty