Provider Demographics
NPI:1487700431
Name:EDEGRAN, DEBBIE KIM (OD)
Entity type:Individual
Prefix:DR
First Name:DEBBIE
Middle Name:KIM
Last Name:EDEGRAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DEBBIE
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:520 DURIE AVE
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-2008
Mailing Address - Country:US
Mailing Address - Phone:201-768-2020
Mailing Address - Fax:201-768-5797
Practice Address - Street 1:520 DURIE AVE
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-2008
Practice Address - Country:US
Practice Address - Phone:201-768-2020
Practice Address - Fax:201-768-5797
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4813152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0700170001Medicare NSC
NJU18281Medicare UPIN
NJ7205750001Medicare NSC
521700Medicare PIN