Healthcare Provider Details

I. General information

NPI: 1710310610
Provider Name (Legal Business Name): BRANDON JON WUZZARDO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 LAUREL HEIGHTS DR
BRIDGETON NJ
08302-3635
US

IV. Provider business mailing address

205 LAUREL HEIGHTS DR
BRIDGETON NJ
08302-3635
US

V. Phone/Fax

Practice location:
  • Phone: 856-455-5500
  • Fax: 856-455-5480
Mailing address:
  • Phone: 856-455-5500
  • Fax: 856-455-5480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00649500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: