Basic Information
| Provider Information | |||||||||
| NPI: | 1780707901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY PICKETT | ||||||||
| FirstName: | AIMEE | ||||||||
| MiddleName: | KOREN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAY | ||||||||
| OtherFirstName: | AIMEE | ||||||||
| OtherMiddleName: | KOREN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 40 INDUSTRIAL PARK RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023604884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087468600 | ||||||||
| FaxNumber: | 5087470824 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 INDUSTRIAL PARK RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023604884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087468600 | ||||||||
| FaxNumber: | 5087470824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901004182 | MI | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 4197 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 900E06513 | 01 | BCBS | OTHER | AA227707 | 01 | MA | HARVARD PILGRIM | OTHER | 110014827A | 05 | MA | MEDICAID | 110955 | 01 | EYE MED | OTHER | W1736901 | 01 | MA | MEDICARE, NHIC | OTHER | 7368965 | 01 | MA | CIGNA | OTHER |