Basic Information
| Provider Information | |||||||||
| NPI: | 1487675955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BASTARACHE | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 326 NICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014201914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788100 | ||||||||
| FaxNumber: | 9788788442 | ||||||||
| Practice Location | |||||||||
| Address1: | 326 NICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014201914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788100 | ||||||||
| FaxNumber: | 9788788442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4509 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0799998 | 05 | MA | MEDICAID |