Provider Demographics
NPI:1295834240
Name:ENGLEWOOD EYE ASSOCIATES P.A.
Entity type:Organization
Organization Name:ENGLEWOOD EYE ASSOCIATES P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST ADMINISTRATIVE PRESIDEN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:201-567-2020
Mailing Address - Street 1:28 EAST PALISADE AVENUE
Mailing Address - Street 2:ENGLEWOOD EYE ASSOCIATES
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:201-567-2020
Mailing Address - Fax:
Practice Address - Street 1:28 EAST PALISADE AVENUE
Practice Address - Street 2:ENGLEWOOD EYE ASSOCIATES
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631
Practice Address - Country:US
Practice Address - Phone:201-567-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00409000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT84887Medicare ID - Type Unspecified
NJ024986Medicare ID - Type Unspecified