Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | D-1676 | NJ |
NPI | 1184707184 |
---|---|
Provider Name | Harry Roth |
First Address | Millburn, NJ 07041-1304 |
Second Address | Millburn, NJ 07041-1304 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2006 |
Last Update Date | 10/06/2008 |