1659367472 NPI number — DR. THOMAS F FREDDO OD

Table of content: DR. THOMAS F FREDDO OD (NPI 1659367472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659367472 NPI number — DR. THOMAS F FREDDO OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDDO
Provider First Name:
THOMAS
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

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:
1659367472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 SYLVIA'S LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTPORT
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-636-6107
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UNIVERSITY OF WATERLOO SCHOOL OF OPTOMETRY CLINICS
Provider Second Line Business Practice Location Address:
200 UNIVERSITY AVE, WEST
Provider Business Practice Location Address City Name:
WATERLOO
Provider Business Practice Location Address State Name:
ONTARIO
Provider Business Practice Location Address Postal Code:
N2L3G1
Provider Business Practice Location Address Country Code:
CA
Provider Business Practice Location Address Telephone Number:
519-888-4567
Provider Business Practice Location Address Fax Number:
519-725-0784
Provider Enumeration Date:
09/27/2005

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:  2578 , 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: 150379BMC . This is a "HARVARD PILGRIM HEALTH CA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2222316 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 002578 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0337749 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: W15600 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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