Provider Demographics
NPI:1912917147
Name:OPTOMETRIC PHYSICIANS OF EATONTOWN LLC
Entity Type:Organization
Organization Name:OPTOMETRIC PHYSICIANS OF EATONTOWN LLC
Other - Org Name:EYESFIRST VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:H
Authorized Official - Last Name:GERSHENOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:732-671-7300
Mailing Address - Street 1:RT. 36
Mailing Address - Street 2:OFFICE MAX PLAZA
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724
Mailing Address - Country:US
Mailing Address - Phone:732-542-3050
Mailing Address - Fax:732-542-5999
Practice Address - Street 1:STATE HIGHWAY 36
Practice Address - Street 2:OFFICE MAX PLAZA
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724
Practice Address - Country:US
Practice Address - Phone:732-542-3050
Practice Address - Fax:732-542-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00570801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0093629Medicaid
NJ0093629Medicaid
NJ100468Medicare PIN