Provider Demographics
NPI:1740374982
Name:TERESCHENKO, MARIANNA (OD)
Entity type:Individual
Prefix:
First Name:MARIANNA
Middle Name:
Last Name:TERESCHENKO
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 1:112 EISENHOWER PKWY
Mailing Address - Street 2:C/O LENSCRAFTERS
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-4995
Mailing Address - Country:US
Mailing Address - Phone:973-535-1171
Mailing Address - Fax:
Practice Address - Street 1:112 EISENHOWER PKWY
Practice Address - Street 2:C/O LENSCRAFTERS
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4995
Practice Address - Country:US
Practice Address - Phone:973-535-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA05891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU98944Medicare UPIN
NJ078047Medicare PIN