Basic Information
Provider Information | |||||||||
NPI: | 1841390937 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WADMAN | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | WINFIELD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 489 BERNARDSTON RD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | GREENFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 013011238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137722571 | ||||||||
FaxNumber: | 4137722266 | ||||||||
Practice Location | |||||||||
Address1: | 489 BERNARDSTON RD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | GREENFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 013011238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137722571 | ||||||||
FaxNumber: | 4137722266 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2006 | ||||||||
LastUpdateDate: | 01/14/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3259 | MA | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 0353787 | 05 | MA |   | MEDICAID | 453866398 | 01 | MA | COMMONWEALTH INDEMNITY PLAN | OTHER | 453866398 | 01 | MA | AARP | OTHER | Y70858 | 01 | MA | BCBS OF MA | OTHER | 453866398 | 01 | MA | HEALTHNET BOSTON MEDICAL | OTHER | 453866398 | 01 | MA | UNICARE | OTHER | 453866398 | 01 | MA | AETNA-ALL | OTHER | 453866398 | 01 | MA | UNITED HEALTH CARE | OTHER | 453866398 | 01 | MA | CIGNA ALL | OTHER | 453866398 | 01 | MA | HARVARD PILGRIM | OTHER | 17524 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 731386 | 01 | MA | TUFTS | OTHER |