=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619798543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNMARIE BARSOUM OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2024
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 HOWE AVE
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-777-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 KINDERKAMACK RD UNIT 683
-----------------------------------------------------
City | HACKENSACK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07601-4880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-856-1768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 125Q00000X
-----------------------------------------------------
Taxonomy Name | Oral Medicine Dentistry
-----------------------------------------------------
License Number | 27OM00200100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 27OA00732600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------