Provider Demographics
NPI:1538190236
Name:MUCK, WAYNE ALLAN (OD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ALLAN
Last Name:MUCK
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 1:222 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2619
Mailing Address - Country:US
Mailing Address - Phone:732-462-0177
Mailing Address - Fax:732-462-5680
Practice Address - Street 1:222 SOUTH ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2619
Practice Address - Country:US
Practice Address - Phone:732-462-0177
Practice Address - Fax:732-462-5680
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00300900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1686305Medicaid
NJU29076Medicare UPIN
NJ1686305Medicaid