Healthcare Provider Details

I. General information

NPI: 1073921508
Provider Name (Legal Business Name): DAVID ALEX SAMUEL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 ALLEN RD
BASKING RIDGE NJ
07920-3848
US

IV. Provider business mailing address

554 ALLEN RD
BASKING RIDGE NJ
07920-3848
US

V. Phone/Fax

Practice location:
  • Phone: 908-224-1608
  • Fax: 908-224-1609
Mailing address:
  • Phone: 908-224-1608
  • Fax: 908-224-1609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00654700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: