Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 27OA00598300 | NJ |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 27OA00598300 | NJ |
N | 152WS0006X | Sports Vision | 27OA00598300 | NJ |
NPI | 1306880257 |
---|---|
Provider Name | Dr. Albert J Staab |
First Address | Marlton, NJ 08053-1747 |
Second Address | Marlton, NJ 08053-1747 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2006 |
Last Update Date | 21/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P00401966 | RAILROAD MEDICARE PROVIDER TRANSACTION NUMBER PTAN (01) | NJ |
V06932 | (02) |