Provider Demographics
NPI:1477504538
Name:BERTOLI, LEONARD (OD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:
Last Name:BERTOLI
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 1:2921 ERIE BLVD E
Mailing Address - Street 2:C/O EMPIRE VISION CENTER, INC
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1430
Mailing Address - Country:US
Mailing Address - Phone:315-445-7465
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:1 HIGHLAND AVE
Practice Address - Street 2:#3B MASS OPTOMETRIC ASSOCIATES, P.C.
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148
Practice Address - Country:US
Practice Address - Phone:781-321-9039
Practice Address - Fax:781-321-8611
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0393738Medicaid
MAW16004Medicare ID - Type Unspecified
MA0393738Medicaid
NHRE3585Medicare PIN