Provider Demographics
NPI:1336742816
Name:ESTACIO, JESSE CORRES (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:CORRES
Last Name:ESTACIO
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 1:30 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-2003
Mailing Address - Country:US
Mailing Address - Phone:201-543-8774
Mailing Address - Fax:
Practice Address - Street 1:2401 ROUTE 22 W
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-8519
Practice Address - Country:US
Practice Address - Phone:908-378-1821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00701700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist