Provider Demographics
NPI:1972823763
Name:GUTMAN, JUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:GUTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3112
Mailing Address - Country:US
Mailing Address - Phone:973-987-3380
Mailing Address - Fax:973-987-3379
Practice Address - Street 1:1255 BROAD ST STE 104
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3061
Practice Address - Country:US
Practice Address - Phone:973-707-5632
Practice Address - Fax:973-707-7349
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6404207W00000X
NJ25MA10052400207WX0107X, 207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ579530Medicaid