Basic Information
| Provider Information | |||||||||
| NPI: | 1477504538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTOLI | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2921 ERIE BLVD E | ||||||||
| Address2: | C/O EMPIRE VISION CENTER, INC | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132241430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154457465 | ||||||||
| FaxNumber: | 3154457675 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HIGHLAND AVE | ||||||||
| Address2: | #3B MASS OPTOMETRIC ASSOCIATES, P.C. | ||||||||
| City: | MALDEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813219039 | ||||||||
| FaxNumber: | 7813218611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 09/20/2007 | ||||||||
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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 | 3490 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0393738 | 05 | MA | MEDICAID |