Provider Demographics
NPI:1811924095
Name:EHRENWORTH, STEVEN L (O,D)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:L
Last Name:EHRENWORTH
Suffix:
Gender:M
Credentials:O,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5803
Mailing Address - Country:US
Mailing Address - Phone:201-342-4255
Mailing Address - Fax:
Practice Address - Street 1:348 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5803
Practice Address - Country:US
Practice Address - Phone:201-342-4255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00384500152W00000X
NJ27TO00046000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0611107Medicaid
NJ0611107Medicaid
NJ521322NURMedicare PIN