Provider Demographics
NPI:1356311062
Name:BOURNE, IRA ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:ROBERT
Last Name:BOURNE
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 1:505 TREMONT ST
Mailing Address - Street 2:APT 210
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-6398
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 ST. JAMES AVE
Practice Address - Street 2:SUITE 135
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116
Practice Address - Country:US
Practice Address - Phone:617-426-6277
Practice Address - Fax:617-426-1251
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW15325OtherBC/BS
MA0301655Medicaid
MAAA211OtherHARVARD PILGRIM
MAMA2241OtherEYE MED
MAAA211OtherHARVARD PILGRIM