Provider Demographics
NPI:1821074923
Name:SHUSTER, KENNETH A (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:SHUSTER
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 1:4827 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:VENTNOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08406-3004
Mailing Address - Country:US
Mailing Address - Phone:609-487-0010
Mailing Address - Fax:609-487-0163
Practice Address - Street 1:4827 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:VENTNOR
Practice Address - State:NJ
Practice Address - Zip Code:08406-3004
Practice Address - Country:US
Practice Address - Phone:609-487-0010
Practice Address - Fax:609-487-0163
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ03856152W00000X
NJ24500152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0613460002OtherOTHER
NJ1867008Medicaid
NJ222832881OtherEIN
NJU26653Medicare UPIN
NJ222832881OtherEIN