Provider Demographics
NPI:1700977857
Name:COYLE, EDWARD MARK JR
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:MARK
Last Name:COYLE
Suffix:JR
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 1:907 WHITEHORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:OAKLYN
Mailing Address - State:NJ
Mailing Address - Zip Code:08107
Mailing Address - Country:US
Mailing Address - Phone:856-854-8004
Mailing Address - Fax:856-854-8004
Practice Address - Street 1:907 WHITEHORSE PIKE
Practice Address - Street 2:
Practice Address - City:OAKLYN
Practice Address - State:NJ
Practice Address - Zip Code:08107
Practice Address - Country:US
Practice Address - Phone:856-854-8004
Practice Address - Fax:856-854-8004
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00199700156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1763620001Medicare ID - Type Unspecified