Provider Demographics
NPI:1669566428
Name:ROCHESTER, CLETTA A (OD)
Entity type:Individual
Prefix:DR
First Name:CLETTA
Middle Name:A
Last Name:ROCHESTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-4510
Mailing Address - Country:US
Mailing Address - Phone:201-434-8833
Mailing Address - Fax:
Practice Address - Street 1:2 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-4510
Practice Address - Country:US
Practice Address - Phone:201-434-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OAOO455900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ38968OtherDAVIS VISION
NJ0639001Medicaid
NJ116128OtherECPA
NJ25552OtherAETNA
NJ6599874OtherGHI
NJ6599874OtherGHI
NJU02008Medicare UPIN