Provider Demographics
NPI:1265021703
Name:MAM, KATHERINE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:MAM
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 1:27 OLD STONEHILL RD
Mailing Address - Street 2:
Mailing Address - City:TYNGSBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01879-2544
Mailing Address - Country:US
Mailing Address - Phone:978-987-3702
Mailing Address - Fax:
Practice Address - Street 1:516 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1816
Practice Address - Country:US
Practice Address - Phone:508-586-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
MA5445152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program