1558561753 NPI number — MASS OPTOMETRIC ASSOCIATES, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558561753 NPI number — MASS OPTOMETRIC ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASS OPTOMETRIC ASSOCIATES, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558561753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 E HOUSTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78205-2299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-340-0219
Provider Business Mailing Address Fax Number:
210-524-6587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1168 MASSACHUSETTS AVE
Provider Second Line Business Practice Location Address:
HARVARD SQUARE
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02138-5205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-547-6080
Provider Business Practice Location Address Fax Number:
617-576-9223
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCDONALD
Authorized Official First Name:
DOLSIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
726-444-4078

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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