Provider Demographics
NPI:1114986361
Name:FRADKIN, RUSSELL (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:FRADKIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:WHITINSVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01588
Mailing Address - Country:US
Mailing Address - Phone:508-234-6681
Mailing Address - Fax:508-234-6507
Practice Address - Street 1:999 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:WHITINSVILLE
Practice Address - State:MA
Practice Address - Zip Code:01588
Practice Address - Country:US
Practice Address - Phone:508-234-6681
Practice Address - Fax:508-234-6507
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2699152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA725524OtherTUFTS HEALTH PLAN
MAW15622OtherBLUE CROSS OF MASS
MA0333913Medicaid
6000000019OtherHARVARD PILGRIM HEALTHCAR
MAW20190OtherBLUE CROSS OF MASS
T59298Medicare UPIN
MAW20190OtherBLUE CROSS OF MASS