Provider Demographics
NPI:1154324309
Name:NAIDETH, NELL RAE (OD)
Entity Type:Individual
Prefix:DR
First Name:NELL
Middle Name:RAE
Last Name:NAIDETH
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 1:285 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-4303
Mailing Address - Country:US
Mailing Address - Phone:978-342-1837
Mailing Address - Fax:
Practice Address - Street 1:285 MAIN ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-4303
Practice Address - Country:US
Practice Address - Phone:978-342-1837
Practice Address - Fax:978-345-7751
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW20145OtherBLUE CROSS
MA110012083/AMedicaid
MA110012083/AMedicaid
MAW20145OtherBLUE CROSS
MA0480790001Medicare NSC