Provider Demographics
NPI:1871628263
Name:DU BOIS, GEORGE EDWARD
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:EDWARD
Last Name:DU BOIS
Suffix:
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 1:4350 ROUTE 42
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-1713
Mailing Address - Country:US
Mailing Address - Phone:856-728-1222
Mailing Address - Fax:856-728-0359
Practice Address - Street 1:4350 ROUTE 42
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-1713
Practice Address - Country:US
Practice Address - Phone:856-728-1222
Practice Address - Fax:856-728-0359
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD-1002156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNSC#0719170001Medicare ID - Type Unspecified