Provider Demographics
NPI:1023586179
Name:BEDZRAH, JACOB (OD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:BEDZRAH
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 1:99 LONGVIEW ST
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4857
Mailing Address - Country:US
Mailing Address - Phone:973-901-5042
Mailing Address - Fax:
Practice Address - Street 1:301 MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-2130
Practice Address - Country:US
Practice Address - Phone:973-668-3579
Practice Address - Fax:973-442-1777
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008908152W00000X
NJ27OA00684500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist