Provider Demographics
NPI:1215987888
Name:DERIENZO, FRANK (OD)
Entity type:Individual
Prefix:DR
First Name:FRANK
Middle Name:
Last Name:DERIENZO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 RIVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07310-1615
Mailing Address - Country:US
Mailing Address - Phone:201-222-3937
Mailing Address - Fax:201-798-6021
Practice Address - Street 1:123 RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07310-1615
Practice Address - Country:US
Practice Address - Phone:201-222-3937
Practice Address - Fax:201-798-6021
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA000470600152WX0102X
NYTUV004989152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04001052Medicaid
NJT91461Medicare UPIN