Healthcare Provider Details

I. General information

NPI: 1376737924
Provider Name (Legal Business Name): MONIKA WYSOCZANSKA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 US HIGHWAY 9
MANALAPAN NJ
07726-3284
US

IV. Provider business mailing address

22 SUNSET DR
PORT READING NJ
07064-1426
US

V. Phone/Fax

Practice location:
  • Phone: 732-972-2221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00611200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: