Provider Demographics
NPI:1609891092
Name:MACKEY, BRIAN M (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:MACKEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:77 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FANWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07023-1422
Mailing Address - Country:US
Mailing Address - Phone:908-889-6256
Mailing Address - Fax:
Practice Address - Street 1:369 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07922-1170
Practice Address - Country:US
Practice Address - Phone:908-464-0123
Practice Address - Fax:908-665-2936
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA05532300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ006942Medicare ID - Type Unspecified
NJU58539Medicare UPIN