Provider Demographics
NPI:1255581609
Name:RIVERDALE VISION CARE, P.A.
Entity type:Organization
Organization Name:RIVERDALE VISION CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUDAPORN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANPATTANA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:917-623-7129
Mailing Address - Street 1:105 GREENE ST
Mailing Address - Street 2:APT 1502
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-3848
Mailing Address - Country:US
Mailing Address - Phone:917-623-7129
Mailing Address - Fax:
Practice Address - Street 1:92 ROUTE 23 NORTH
Practice Address - Street 2:SUITE E
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457
Practice Address - Country:US
Practice Address - Phone:917-623-7129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA 00594603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU98400Medicare UPIN