Provider Demographics
NPI:1225139744
Name:FANTAZIAN, JAMES HOVANNES (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:HOVANNES
Last Name:FANTAZIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:247 BOSTON RD
Mailing Address - City:N BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01862
Mailing Address - Country:US
Mailing Address - Phone:978-667-6151
Mailing Address - Fax:978-667-4422
Practice Address - Street 1:247 BOSTON RD
Practice Address - Street 2:
Practice Address - City:N BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01862
Practice Address - Country:US
Practice Address - Phone:978-667-6151
Practice Address - Fax:978-667-4422
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2093152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0304999Medicaid
FA11305841Medicare ID - Type Unspecified
MA0304999Medicaid