Provider Demographics
NPI:1386328201
Name:CHISM, REYNOLDS WILLIAM
Entity type:Individual
Prefix:
First Name:REYNOLDS
Middle Name:WILLIAM
Last Name:CHISM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 ROUTE 9 N
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1004
Mailing Address - Country:US
Mailing Address - Phone:732-826-6932
Mailing Address - Fax:732-826-6936
Practice Address - Street 1:306 ROUTE 9 N
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-1004
Practice Address - Country:US
Practice Address - Phone:732-826-6932
Practice Address - Fax:732-826-6936
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00376400156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician