Basic Information
| Provider Information | |||||||||
| NPI: | 1689609505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 NEWTON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017721215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084815500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24 NEWTON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBORO | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084603150 | ||||||||
| FaxNumber: | 5084603061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2230 | MA | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 00331 | RI | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0354007 | 05 | MA | MEDICAID | 763274 | 01 | TUFTS | OTHER |