Healthcare Provider Details

I. General information

NPI: 1144459165
Provider Name (Legal Business Name): KATERINA BUBNOVSKY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2009
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 APPLEGARTH RD
MONROE TOWNSHIP NJ
08831-3721
US

IV. Provider business mailing address

337 APPLEGARTH RD
MONROE TOWNSHIP NJ
08831-3721
US

V. Phone/Fax

Practice location:
  • Phone: 609-883-4407
  • Fax:
Mailing address:
  • Phone: 609-555-2666
  • Fax: 609-655-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number270A00619300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: