Basic Information
Provider Information | |||||||||
NPI: | 1629365093 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FEUCHT | ||||||||
FirstName: | NICHOLAS | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 488 PLEASANT ST | ||||||||
Address2: |   | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016091857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087566832 | ||||||||
FaxNumber: | 5087565260 | ||||||||
Practice Location | |||||||||
Address1: | 891 WESTMINSTER ST | ||||||||
Address2: |   | ||||||||
City: | PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029034020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4013317850 | ||||||||
FaxNumber: | 4012744739 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2011 | ||||||||
LastUpdateDate: | 10/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046010482 | IL | N |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | ODTG00604 | RI | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 502720042 | 01 | IL | MEDICARE PTAN | OTHER | 046010482 | 05 | IL |   | MEDICAID |