Healthcare Provider Details

I. General information

NPI: 1720097157
Provider Name (Legal Business Name): GREGG ALLEN BANNETT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N BROAD ST
WOODBURY NJ
08096-1795
US

IV. Provider business mailing address

620 N BROAD ST
WOODBURY NJ
08096-1795
US

V. Phone/Fax

Practice location:
  • Phone: 856-853-5554
  • Fax: 856-853-5650
Mailing address:
  • Phone: 856-853-5554
  • Fax: 856-853-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MB04846500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MB04846500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: