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General NPI Number Information
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NPI Number | 1912943440
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Entity Type | Organization
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Legal Business Name | WISDA EYE CENTER PC
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Dates
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Enumeration Date | 06/22/2006
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Last Update Date | 08/23/2010
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Provider Practice Location Address
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Address Line | 1318 S MAIN RD BLDG. 2A
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City | VINELAND
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State | NJ
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Zip | 08360-6516
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Country | US
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Telephone | 856-692-8008
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Fax | 856-692-8044
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Provider Business Mailing Address
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Address Line | 1318 S MAIN RD BLDG. 2A
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City | VINELAND
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State | NJ
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Zip | 08360-6516
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Country | US
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Telephone | 856-692-8008
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Fax | 856-692-8044
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JOANNE LOGAN
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Credential |
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Telephone | 856-692-8008
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 25MA05025100
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License Number State | NJ
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