Provider Demographics
NPI:1366455032
Name:OPTICAL WORLD OF ELIZABETH LLC
Entity type:Organization
Organization Name:OPTICAL WORLD OF ELIZABETH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUKUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAITHATHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-629-0011
Mailing Address - Street 1:206 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-2304
Mailing Address - Country:US
Mailing Address - Phone:908-629-0011
Mailing Address - Fax:908-629-1133
Practice Address - Street 1:206 BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201-2304
Practice Address - Country:US
Practice Address - Phone:908-629-0011
Practice Address - Fax:908-629-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28188OtherSPECTERA
NJ51599OtherDAVIS VISION
NJ0072460Medicaid