Basic Information
| Provider Information | |||||||||
| NPI: | 1770532087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTOMETRIC PROVIDERS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2921 ERIE BLVD E | ||||||||
| Address2: | OPTOMETRIC PROVIDERS INC | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154463145 | ||||||||
| FaxNumber: | 3154457675 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HIGHLAND AVE | ||||||||
| Address2: | #3B | ||||||||
| City: | MALDEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813219039 | ||||||||
| FaxNumber: | 7813218611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | IACOBBO | ||||||||
| AuthorizedOfficialFirstName: | ALERINO | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3154463145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 9781048 | 05 | MA | MEDICAID |