Provider Demographics
NPI:1417484056
Name:BERTOLET, ANNE NICOLLE (OD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:NICOLLE
Last Name:BERTOLET
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 1:150 S HUNTINGTON AVE
Mailing Address - Street 2:MAIL CODE 112
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:802-881-9275
Mailing Address - Fax:
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:617-232-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-14
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5340152W00000X
PAOEG003286152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist