Healthcare Provider Details

I. General information

NPI: 1407893019
Provider Name (Legal Business Name): MEDFORD EYEWEAR CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TUCKERTON RD STORE 2
MEDFORD NJ
08055-8806
US

IV. Provider business mailing address

200 TUCKERTON RD STORE 2
MEDFORD NJ
08055-8806
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-8887
  • Fax: 856-983-4757
Mailing address:
  • Phone: 856-983-8887
  • Fax: 856-983-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4996
License Number StateNJ

VIII. Authorized Official

Name: DR. GARY S EDELSTEIN
Title or Position: OWNER
Credential: OD
Phone: 856-983-8887