Basic Information
| Provider Information | |||||||||
| NPI: | 1962402644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYONS | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 COMMON WEALTH AVE SUITE 2A | ||||||||
| Address2: | NEW ENGLAND EYE INSTITUE | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172622020 | ||||||||
| FaxNumber: | 6172366323 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 FLAGG DRIVE | ||||||||
| Address2: | NEW ENGLAND EYE FULLER MIDDLE SCHOOL | ||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086204956 | ||||||||
| FaxNumber: | 5088794909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 12/28/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3440 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 324370 | 05 | MA | MEDICAID |