Basic Information
| Provider Information | |||||||||
| NPI: | 1902992886 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABBONDANZA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 TURNPIKE RD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017722114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084818558 | ||||||||
| FaxNumber: | 5088483057 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 TURNPIKE RD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017722114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084818558 | ||||||||
| FaxNumber: | 5088483057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 05/19/2014 | ||||||||
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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 | 3407 | MA | N | Eye and Vision Services Providers | Optometrist | 152WP0200X | 3407 | MA | Y | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WV0400X | 3407 | MA | N | Eye and Vision Services Providers | Optometrist | Vision Therapy |
ID Information
| ID | Type | State | Issuer | Description | 0369322 | 05 | MA | MEDICAID |