Provider Demographics
NPI:1518068923
Name:PHILLIPS, LAWRENCE A (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:A
Last Name:PHILLIPS
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 1:199 BROOKLINE ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2802
Mailing Address - Country:US
Mailing Address - Phone:617-547-3310
Mailing Address - Fax:617-497-2025
Practice Address - Street 1:40 BRATTLE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-3712
Practice Address - Country:US
Practice Address - Phone:617-547-3310
Practice Address - Fax:617-547-3313
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA3642152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0391786Medicaid
MAT441688Medicare UPIN
MA464358Medicare ID - Type UnspecifiedMEDICARE NUMBER