Healthcare Provider Details

I. General information

NPI: 1427767789
Provider Name (Legal Business Name): CLIFFORD JEUDY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4946 N 5TH ST
PHILADELPHIA PA
19120-3810
US

IV. Provider business mailing address

7641 ROOSEVELT BLVD
PHILADELPHIA PA
19152-3917
US

V. Phone/Fax

Practice location:
  • Phone: 215-924-4142
  • Fax: 267-331-8913
Mailing address:
  • Phone: 267-808-3986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: