Provider Demographics
NPI:1750367363
Name:SUYDAM, J J (OD)
Entity type:Individual
Prefix:DR
First Name:J
Middle Name:J
Last Name:SUYDAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2087 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-3211
Mailing Address - Country:US
Mailing Address - Phone:610-323-0133
Mailing Address - Fax:610-323-3224
Practice Address - Street 1:2087 E HIGH ST
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464
Practice Address - Country:US
Practice Address - Phone:610-323-0133
Practice Address - Fax:610-323-3224
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000916152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01156230Medicaid
PA483483H4XMedicare ID - Type Unspecified
PA0199970001Medicare NSC
PA01156230Medicaid