Basic Information
| Provider Information | |||||||||
| NPI: | 1821250952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAPE | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 888 WORCESTER ST | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024823744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 3396862561 | ||||||||
| Practice Location | |||||||||
| Address1: | 438 MAIN ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889646681 | ||||||||
| FaxNumber: | 8886620859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 10/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 002747 | CT | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 007288 | NY | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 03022864 | 05 | NY | MEDICAID | 1821250952 | 05 | CT | MEDICAID |