Provider Demographics
NPI:1790161602
Name:CHRISTOPHER, GUSTIE (OD)
Entity Type:Individual
Prefix:
First Name:GUSTIE
Middle Name:
Last Name:CHRISTOPHER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LAWRENCE ST
Mailing Address - Street 2:PH 32
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4631
Mailing Address - Country:US
Mailing Address - Phone:305-879-9881
Mailing Address - Fax:
Practice Address - Street 1:154 ROUTE 10 WEST
Practice Address - Street 2:UNIT 4B
Practice Address - City:EAST HAVOVER
Practice Address - State:NJ
Practice Address - Zip Code:07936-2107
Practice Address - Country:US
Practice Address - Phone:973-887-0216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270800662000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist