Provider Demographics
NPI:1164814539
Name:KADDOUR, MUSTAPHA
Entity Type:Individual
Prefix:MR
First Name:MUSTAPHA
Middle Name:
Last Name:KADDOUR
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 1:222 BERGEN BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAIRVIEW
Mailing Address - State:NJ
Mailing Address - Zip Code:07022-1300
Mailing Address - Country:US
Mailing Address - Phone:201-945-2525
Mailing Address - Fax:201-945-2528
Practice Address - Street 1:222 BERGEN BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:FAIRVIEW
Practice Address - State:NJ
Practice Address - Zip Code:07022-1300
Practice Address - Country:US
Practice Address - Phone:201-945-2525
Practice Address - Fax:201-945-2528
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00604800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist