Provider Demographics
NPI:1437272051
Name:MEDFORD EYEGLASS SHOP INC.
Entity Type:Organization
Organization Name:MEDFORD EYEGLASS SHOP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RICCARDO
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUZZANGA
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:781-391-4069
Mailing Address - Street 1:466 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3343
Mailing Address - Country:US
Mailing Address - Phone:781-391-4069
Mailing Address - Fax:
Practice Address - Street 1:466 SALEM ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3343
Practice Address - Country:US
Practice Address - Phone:781-391-4069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4427156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1512005Medicaid