Provider Demographics
NPI:1366480659
Name:NIEMCZYK, EDWARD V (OD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:V
Last Name:NIEMCZYK
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 1:1 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH JUNCTION
Mailing Address - State:NJ
Mailing Address - Zip Code:08852-2407
Mailing Address - Country:US
Mailing Address - Phone:732-297-7575
Mailing Address - Fax:
Practice Address - Street 1:1 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:MONMOUTH JUNCTION
Practice Address - State:NJ
Practice Address - Zip Code:08852-2407
Practice Address - Country:US
Practice Address - Phone:732-297-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00415800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNI006864Medicare PIN
NJU23948Medicare UPIN