Provider Demographics
NPI:1811059785
Name:MORILLO, DIEGO XAVIER (OD)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:XAVIER
Last Name:MORILLO
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 1:1386 ALPS RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3604
Mailing Address - Country:US
Mailing Address - Phone:973-872-6650
Mailing Address - Fax:201-712-9838
Practice Address - Street 1:875 BROAD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2622
Practice Address - Country:US
Practice Address - Phone:973-622-4492
Practice Address - Fax:973-622-5919
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00566203152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ29726OtherSPECTERA INSURANCE
NJOP1793OtherEYEMED INSURANCE
NJ8277508Medicaid
NJ2428558OtherAETNA
NJ52588OtherDAVIS VISION INSURANCE
NJ8277508Medicaid
NJ29726OtherSPECTERA INSURANCE