Healthcare Provider Details

I. General information

NPI: 1750367363
Provider Name (Legal Business Name): J J SUYDAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2087 E HIGH ST
POTTSTOWN PA
19464
US

IV. Provider business mailing address

2087 E HIGH ST
POTTSTOWN PA
19464-3211
US

V. Phone/Fax

Practice location:
  • Phone: 610-323-0133
  • Fax: 610-323-3224
Mailing address:
  • Phone: 610-323-0133
  • Fax: 610-323-3224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000916
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01156230
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: