1689754418 NPI number — DR. JAY DEMESQUITA O.D.

Table of content: DR. JAY DEMESQUITA O.D. (NPI 1689754418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689754418 NPI number — DR. JAY DEMESQUITA O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMESQUITA
Provider First Name:
JAY
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1689754418
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4222 WESTFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENNSAUKEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08110-3010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-964-1058
Provider Business Mailing Address Fax Number:
856-662-0299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4222 WESTFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENNSAUKEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08110-3010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-964-1058
Provider Business Practice Location Address Fax Number:
856-662-0299
Provider Enumeration Date:
10/16/2006

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: 152W00000X , with the licence number:  27OA00367000 , 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: 1373501 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0K9077 . This is a "HEALTH NET MATERIALS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: F09873 . This is a "HEALTH NET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 18220 . This is a "SPECTERA/AMERICHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 33221 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: NJ03620 . This is a "VISION BENEFITS OF AMERIC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 310045 . This is a "NATL VISION ADMINISTRATOR" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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