Provider Demographics
NPI:1023061348
Name:NISSINOFF, RANDY S (OD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:S
Last Name:NISSINOFF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1278 HOOPER AVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-3324
Mailing Address - Country:US
Mailing Address - Phone:732-505-0533
Mailing Address - Fax:732-505-6572
Practice Address - Street 1:1278 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-3324
Practice Address - Country:US
Practice Address - Phone:732-505-0533
Practice Address - Fax:732-505-6572
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00506100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ043721860OtherTAX IDENTIFICATION
NJ204100761OtherTAX IDENTIFICATION
NJ223791991OtherTAX IDENTIFICATION
NJ204100926OtherTAX IDENTIFICATION
NJ23545OtherNVA
NJ1316769OtherAETNA
NJ23731OtherNVA
NJ2855956OtherAETNA
NJ311501OtherNVA
NJ22678OtherNVA
NJ3843273OtherAETNA
NJ62810OtherLOCAL 825 OPERATING ENGINEERS
NJ911575OtherEYE MED
NJ1316771OtherAETNA
NJ510661700OtherTAX IDENTIFICATION
NJ203095550OtherTAX IDENTIFICATION
NJ1316770OtherAETNA
NJ23793OtherNVA
NJ510661700OtherTAX IDENTIFICATION
MDU00832Medicare UPIN