Provider Demographics
NPI:1780708099
Name:GOETZ, PETER A (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:A
Last Name:GOETZ
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-3558
Mailing Address - Country:US
Mailing Address - Phone:732-223-2020
Mailing Address - Fax:
Practice Address - Street 1:134 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-3558
Practice Address - Country:US
Practice Address - Phone:732-223-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00185200156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2222259035OtherTAX ID
NJ7425406Medicaid
NJ0714800001Medicare ID - Type Unspecified