Provider Demographics
NPI:1013998939
Name:AVERGON, MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:AVERGON
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 1:620 CRANBURY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4098
Mailing Address - Country:US
Mailing Address - Phone:732-238-0393
Mailing Address - Fax:732-238-6393
Practice Address - Street 1:620 CRANBURY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-4098
Practice Address - Country:US
Practice Address - Phone:732-238-0393
Practice Address - Fax:732-238-6393
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA00547300152W00000X
NJTO00085100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7304803Medicaid
NJ527710Medicare ID - Type Unspecified
NJU66583Medicare UPIN