Provider Demographics
NPI:1104983121
Name:KAHWATY, ROBIN (OD)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:KAHWATY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 KONNER AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9524
Mailing Address - Country:US
Mailing Address - Phone:973-890-2772
Mailing Address - Fax:
Practice Address - Street 1:77 WILLOWBROOK BLVD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7055
Practice Address - Country:US
Practice Address - Phone:973-890-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00524000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU52649Medicare UPIN
NJ538853Medicare ID - Type Unspecified