Basic Information
| Provider Information | |||||||||
| NPI: | 1598709289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'DONOGHUE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 COMMONWEALTH AVE SUITE 2 | ||||||||
| Address2: | NEW ENGLAND EYE INSTITUTE | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175875511 | ||||||||
| FaxNumber: | 6172366323 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 COMMONWEALTH AVE SUITE 2A | ||||||||
| Address2: | NEW ENGLAND EYE COMMONWEALTH | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172622020 | ||||||||
| FaxNumber: | 6172366323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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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 | 3023 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | AA62951 | 01 | HARVARD PILGRAM | OTHER | W15574 | 01 | BLUE CROSS B S OF MA | OTHER | 152627 | 01 | HARVARD PILGRAM HLTH CARE | OTHER | 0346322 | 05 | MA | MEDICAID | 755398 | 01 | TUFTS HEALTH PLAN | OTHER |