Healthcare Provider Details

I. General information

NPI: 1679556146
Provider Name (Legal Business Name): WALTER JOHN SHURMINSKY JR. OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 CENTRE ST
NUTLEY NJ
07110-1635
US

IV. Provider business mailing address

18 FAWN HILL DR
MAHWAH NJ
07430-2829
US

V. Phone/Fax

Practice location:
  • Phone: 973-667-0331
  • Fax: 973-667-9673
Mailing address:
  • Phone: 201-934-7317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number270A00467800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: