Provider Demographics
NPI:1003247255
Name:DEDHAM OPHTHALMIC CONSULTANTS AND SURGEONS, P.C.
Entity Type:Organization
Organization Name:DEDHAM OPHTHALMIC CONSULTANTS AND SURGEONS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:GILLIES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-251-2222
Mailing Address - Street 1:980 WASHINGTON ST
Mailing Address - Street 2:SUITE120
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-6731
Mailing Address - Country:US
Mailing Address - Phone:781-251-2222
Mailing Address - Fax:781-234-0279
Practice Address - Street 1:980 WASHINGTON ST
Practice Address - Street 2:SUITE120
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-6731
Practice Address - Country:US
Practice Address - Phone:781-251-2222
Practice Address - Fax:781-234-0279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6070110001OtherMEDICARE PTAN