Provider Demographics
NPI:1104977073
Name:GRAFF DISTENFELD, AVIVA C (OD)
Entity type:Individual
Prefix:
First Name:AVIVA
Middle Name:C
Last Name:GRAFF DISTENFELD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:680 BROADWAY
Mailing Address - Street 2:STE 114
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07514-1526
Mailing Address - Country:US
Mailing Address - Phone:973-742-4747
Mailing Address - Fax:973-742-0629
Practice Address - Street 1:680 BROADWAY
Practice Address - Street 2:SUITE 114
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1422
Practice Address - Country:US
Practice Address - Phone:973-742-4747
Practice Address - Fax:973-742-0629
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00585100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ120440QN9Medicare PIN