Provider Demographics
NPI:1154698975
Name:OPTIMUM PRI-MED CARE PA
Entity type:Organization
Organization Name:OPTIMUM PRI-MED CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEON-WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-476-2528
Mailing Address - Street 1:293 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-5209
Mailing Address - Country:US
Mailing Address - Phone:973-476-2528
Mailing Address - Fax:
Practice Address - Street 1:293 MONROE ST
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5209
Practice Address - Country:US
Practice Address - Phone:973-476-2528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05907400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty