Healthcare Provider Details

I. General information

NPI: 1861184616
Provider Name (Legal Business Name): MICHAEL SIMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 07/01/2023
Certification Date: 07/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 HIGHWAY 77
BRIDGETON NJ
08302-5988
US

IV. Provider business mailing address

1130 HIGHWAY 77
BRIDGETON NJ
08302-5988
US

V. Phone/Fax

Practice location:
  • Phone: 856-453-2739
  • Fax: 856-453-2802
Mailing address:
  • Phone: 856-453-2739
  • Fax: 856-453-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number31TD00408200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: