1073654802 NPI number — DR. GLENNA ANNE WAITT O.D.

Table of content: DR. GLENNA ANNE WAITT O.D. (NPI 1073654802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073654802 NPI number — DR. GLENNA ANNE WAITT O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAITT
Provider First Name:
GLENNA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1073654802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
74 SURF AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02050-6746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-834-2235
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BJS OPTICAL
Provider Second Line Business Practice Location Address:
GLENNA WAITT OD
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-732-0420
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2957 , 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)

  • Identifier: 2957 . This is a "STATE LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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