Basic Information
| Provider Information | |||||||||
| NPI: | 1851585244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTOMETRY ASSOCIATES OF WORCESTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 488 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016091857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087566832 | ||||||||
| FaxNumber: | 5087565266 | ||||||||
| Practice Location | |||||||||
| Address1: | 488 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016091857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087566832 | ||||||||
| FaxNumber: | 5087565266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2007 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | GROSSMAN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5087566832 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 2398 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
ID Information
| ID | Type | State | Issuer | Description | 9702318 | 05 | MA | MEDICAID |