MEDICARE: WISDA EYE CENTER PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	25MA05025100	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912943440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISDA EYE CENTER PC

Provider Business Mailing Address
First Line	:	1318 S MAIN RD
Second Line	:	BLDG. 2A
City	:	VINELAND
State	:	NJ
Zip	:	08360-6516
Country	:	US
Telephone Number	:	856-692-8008
Fax Number	:	856-692-8044

Provider Business Practice Location Address
First Line	:	1318 S MAIN RD
Second Line	:	BLDG. 2A
City	:	VINELAND
State	:	NJ
Zip	:	08360-6516
Country	:	US
Telephone Number	:	856-692-8008
Fax Number	:	856-692-8044

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JOANNE LOGAN
Credential	:
Telephone Number	:	856-692-8008

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	08/23/2010

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Directions to “WISDA EYE CENTER PC ” Practice Location

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