Provider Demographics
NPI:1528365053
Name:LINO, EDSON
Entity Type:Individual
Prefix:
First Name:EDSON
Middle Name:
Last Name:LINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 SOMERVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-2914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 SOMERVILLE AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-2914
Practice Address - Country:US
Practice Address - Phone:617-776-6300
Practice Address - Fax:617-776-0404
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5128156FC0800X, 156FC0801X, 156FX1700X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician