Provider Demographics
NPI:1063673028
Name:DELISO, KATHRYN W (OD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:W
Last Name:DELISO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LINCOLN SQ
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1135
Mailing Address - Country:US
Mailing Address - Phone:508-373-5830
Mailing Address - Fax:508-519-5512
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2738
Practice Address - Country:US
Practice Address - Phone:508-856-0737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001757152W00000X
MDTA2106152W00000X
MA4786152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist