Provider Demographics
NPI:1962631366
Name:NORWICH OPHTHALMOLOGY OPTICAL, INC.
Entity type:Organization
Organization Name:NORWICH OPHTHALMOLOGY OPTICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-886-0161
Mailing Address - Street 1:79 WAWECUS ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2160
Mailing Address - Country:US
Mailing Address - Phone:860-886-0161
Mailing Address - Fax:860-889-5999
Practice Address - Street 1:188 NORWICH AVE
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1256
Practice Address - Country:US
Practice Address - Phone:860-537-4644
Practice Address - Fax:860-537-2501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORWICH OPHTHALMOLOGY OPTICAL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-07
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000433156FX1800X
CT001624332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008004664Medicaid
CT008004664Medicaid