Provider Demographics
NPI:1912047713
Name:OPHTHALMOLOGY OF MONTCLAIR LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:OPHTHALMOLOGY OF MONTCLAIR LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:PHYLLIS
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-509-6039
Mailing Address - Street 1:33 N FULLERTON AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3412
Mailing Address - Country:US
Mailing Address - Phone:973-509-6039
Mailing Address - Fax:973-509-6069
Practice Address - Street 1:33 N FULLERTON AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3412
Practice Address - Country:US
Practice Address - Phone:973-509-6039
Practice Address - Fax:973-509-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07491800207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ109408Medicare PIN