Basic Information
| Provider Information | |||||||||
| NPI: | 1083630578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUBLIN | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 CAMBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175237006 | ||||||||
| FaxNumber: | 6175235006 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 CAMBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175237006 | ||||||||
| FaxNumber: | 6175235006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 11/23/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3070 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 15635 | 01 | HPHC | OTHER | W15611 | 01 | BCBS | OTHER | 511857 | 01 | UNITED | OTHER |