Provider Demographics
NPI:1649391764
Name:JOHN M. IPPOLITO, OD, PC
Entity type:Organization
Organization Name:JOHN M. IPPOLITO, OD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARIO
Authorized Official - Last Name:IPPOLITO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:908-580-2555
Mailing Address - Street 1:1107 VALLEY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:STIRLING
Mailing Address - State:NJ
Mailing Address - Zip Code:07980-1524
Mailing Address - Country:US
Mailing Address - Phone:908-580-2555
Mailing Address - Fax:908-580-2544
Practice Address - Street 1:1107 VALLEY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:STIRLING
Practice Address - State:NJ
Practice Address - Zip Code:07980-1524
Practice Address - Country:US
Practice Address - Phone:908-580-2555
Practice Address - Fax:908-580-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00542600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ025385RBPMedicare ID - Type UnspecifiedGROUP #
NJ065957Medicare ID - Type UnspecifiedGROUP #