Provider Demographics
NPI:1316191521
Name:FERACO, ROBERTA TEIXEIRA (OD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:TEIXEIRA
Last Name:FERACO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:FERACO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1885 REVERE BEACH PKWY
Mailing Address - Street 2:SUITE 03
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5923
Mailing Address - Country:US
Mailing Address - Phone:617-389-0099
Mailing Address - Fax:617-294-2612
Practice Address - Street 1:1885 REVERE BEACH PKWY
Practice Address - Street 2:SUITE 03
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-5923
Practice Address - Country:US
Practice Address - Phone:617-389-0099
Practice Address - Fax:617-294-2612
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4715152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0727288Medicaid
MA9027228OtherAETNA