1013914175 NPI number — RONALD SIWOFF O.D.

Table of content: RONALD SIWOFF O.D. (NPI 1013914175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013914175 NPI number — RONALD SIWOFF O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIWOFF
Provider First Name:
RONALD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013914175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/20/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 BLOOMFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
DENVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07834-2734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-627-7787
Provider Business Mailing Address Fax Number:
973-627-7701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 BLOOMFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
DENVILLE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07834-2734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-627-7787
Provider Business Practice Location Address Fax Number:
973-627-7701
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WL0500X , with the licence number:  27OA003818 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 410047651 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2795942 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 78022238353240 . This is a "HORIZON BC/BS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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