Provider Demographics
NPI:1083614838
Name:PREVOST, JEANINE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:
Last Name:PREVOST
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 1:1287 WILBUR AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02725-1816
Mailing Address - Country:US
Mailing Address - Phone:508-676-2140
Mailing Address - Fax:
Practice Address - Street 1:1287 WILBUR AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:MA
Practice Address - Zip Code:02725-1816
Practice Address - Country:US
Practice Address - Phone:508-673-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W15984OtherBLUE CROSS BLUE SHIELD OF MASSACHUSETTS
0950210001OtherMEDICARE REGION A DMERC
151265OtherHARVARD PILGRIM HEALTH CARE
4877-6OtherBLUE CROSS OF RI
MA0393827Medicaid
W15984OtherBLUE CROSS BLUE SHIELD OF MASSACHUSETTS
MA0393827Medicaid