Provider Demographics
NPI:1407060361
Name:FOOTE, TIMOTHY M (DISPENSING OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:M
Last Name:FOOTE
Suffix:
Gender:M
Credentials:DISPENSING OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 BELMONT STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5666
Mailing Address - Country:US
Mailing Address - Phone:508-586-2725
Mailing Address - Fax:508-586-2770
Practice Address - Street 1:727 BELMONT STREET
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5666
Practice Address - Country:US
Practice Address - Phone:508-586-2725
Practice Address - Fax:508-586-2770
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1615156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1506773OtherMASSHEALTH PROVIDER NO
MA03306908387OtherMASSHEALTH TRADING PARTNE
MA1506773OtherMASSHEALTH PROVIDER NO