Healthcare Provider Details

I. General information

NPI: 1821071754
Provider Name (Legal Business Name): LIGAYA PRYSTOWSKY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 FRANKLIN AVE
NUTLEY NJ
07110-1209
US

IV. Provider business mailing address

665 FRANKLIN AVE
NUTLEY NJ
07110-1209
US

V. Phone/Fax

Practice location:
  • Phone: 973-667-4008
  • Fax: 973-667-1655
Mailing address:
  • Phone: 973-667-4008
  • Fax: 973-667-1655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MA04185000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: