Basic Information
| Provider Information | |||||||||
| NPI: | 1861450181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODCOME | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 MAIN ST | ||||||||
| Address2: | ATTN: VIRGILIA PIRES | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088943503 | ||||||||
| FaxNumber: | 5085595073 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 MAIN ST | ||||||||
| Address2: | BROCKTON NEIGHBORHOOD HEALTH CENTER | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023014042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088943503 | ||||||||
| FaxNumber: | 5085595073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 10/12/2016 | ||||||||
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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 | 2607 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 00026097302 | 01 | NY | UNIVERA # LTH | OTHER | 101944CS | 01 | NY | PREFERRED CARE # LTH | OTHER | P010003495 | 01 | NY | BLUE CHOICE # LTH | OTHER |