1760456651 NPI number — DR. JENNIFER DAMICO OD

Table of content: DR. JENNIFER DAMICO OD (NPI 1760456651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760456651 NPI number — DR. JENNIFER DAMICO OD

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OCONNOR
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
DAMICO
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1760456651
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
355 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BROOKFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-867-3755
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
355 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH BROOKFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-867-3755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2006

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:  3785 , 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: 981690 . This is a "NETWORK HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: W21011 . This is a "BCBS - GROUP #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0392022 . This is a "MASS HEALTH UNISYS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 151329 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2634580 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57106 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: W21011 . This is a "MEDICARE C&S ADMIN SVCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0392022 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20798 . This is a "CIGNA HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2203040 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2634580 . This is a "AETNA HEALTH INC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 747176 . This is a "CONNECTICARE INC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9777385 . This is a "MASS HEALTH UNISYS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1149190002 . This is a "DMERC METRA HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 732547 . This is a "TUFTS ASSOC HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: W15940 . This is a "BLUE CROSS BLUE SHIELD MA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200 . This is a "ULTRA BENEFITS" identifier . This identifiers is of the category "OTHER".
  • Identifier: W15940 . This is a "MEDICARE C&S ADMIN SVCS" identifier . This identifiers is of the category "OTHER".




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