Healthcare Provider Details

I. General information

NPI: 1417982240
Provider Name (Legal Business Name): JOHN BRIAN CUDLIPP O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 N BROADWAY
PENNSVILLE NJ
08070-1751
US

IV. Provider business mailing address

98 N BROADWAY
PENNSVILLE NJ
08070-1751
US

V. Phone/Fax

Practice location:
  • Phone: 856-678-2465
  • Fax: 856-678-7878
Mailing address:
  • Phone: 856-678-2465
  • Fax: 856-678-7878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4898
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: