Basic Information
| Provider Information | |||||||||
| NPI: | 1629134085 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFREY KUBLIN OD, PC | ||||||||
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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: | 12/29/2006 | ||||||||
| LastUpdateDate: | 07/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | KUBLIN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6175237006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3070 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | W20111 | 01 | MA | BC/BS | OTHER |