Basic Information
| Provider Information | |||||||||
| NPI: | 1902100795 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VISION SOURCE OF AMHERST AND GREENFIELD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NONE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| 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: | 01/07/2011 | ||||||||
| LastUpdateDate: | 01/14/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WADMAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | WINFIELD | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4137722571 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3258 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 17524 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 409258 | 01 | MA | MEDICARE ID-TYPE UNSPECIFIED | OTHER | Y70858 | 01 | MA | BC/BS OF MA | OTHER | 000000021735 | 01 | MA | HEALTHNET BOSTON MEDICAL | OTHER | 0353787 | 05 | MA | MEDICAID |