Healthcare Provider Details

I. General information

NPI: 1912059957
Provider Name (Legal Business Name): JOIE MICHELLE BRODY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 MAIN ST
HACKENSACK NJ
07601-5803
US

IV. Provider business mailing address

348 MAIN ST
HACKENSACK NJ
07601-5803
US

V. Phone/Fax

Practice location:
  • Phone: 201-342-4255
  • Fax: 201-487-4886
Mailing address:
  • Phone: 201-342-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00592200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: