=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366438939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH JERSEY EYE ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2005
-----------------------------------------------------
Last Update Date | 08/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 LAUREL HEIGHTS DR
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08302-3635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-455-5500
-----------------------------------------------------
Fax | 856-455-5480
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 LAUREL HEIGHTS DR
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08302-3635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-455-5500
-----------------------------------------------------
Fax | 856-455-5480
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT M COLE III
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 856-455-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------