Provider Demographics
NPI:1689841231
Name:MADISON OPTICAL
Entity type:Organization
Organization Name:MADISON OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MORIARTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-245-4465
Mailing Address - Street 1:59 BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2632
Mailing Address - Country:US
Mailing Address - Phone:203-245-4465
Mailing Address - Fax:203-245-6996
Practice Address - Street 1:59 BRADLEY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2632
Practice Address - Country:US
Practice Address - Phone:203-245-4465
Practice Address - Fax:203-245-6996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001475156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5498330001Medicare NSC