Provider Demographics
NPI:1912943440
Name:WISDA EYE CENTER PC
Entity type:Organization
Organization Name:WISDA EYE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-692-8008
Mailing Address - Street 1:1318 S MAIN RD
Mailing Address - Street 2:BLDG. 2A
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6516
Mailing Address - Country:US
Mailing Address - Phone:856-692-8008
Mailing Address - Fax:856-692-8044
Practice Address - Street 1:1318 S MAIN RD
Practice Address - Street 2:BLDG. 2A
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6516
Practice Address - Country:US
Practice Address - Phone:856-692-8008
Practice Address - Fax:856-692-8044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05025100207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7014007Medicaid
NJ7014007Medicaid
759163Medicare PIN
NJE53674Medicare UPIN