Provider Demographics
NPI:1538500202
Name:SUPPAPPOLA, AZADEH (OD)
Entity Type:Individual
Prefix:DR
First Name:AZADEH
Middle Name:
Last Name:SUPPAPPOLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AZADEH
Other - Middle Name:
Other - Last Name:KARBASI.
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:25 MARSTON STREET #104
Mailing Address - Street 2:BOSTON EYE GROUP
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841
Mailing Address - Country:US
Mailing Address - Phone:978-685-5366
Mailing Address - Fax:978-685-4867
Practice Address - Street 1:25 MARSTON STREET #104
Practice Address - Street 2:BOSTON EYE GROUP
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841
Practice Address - Country:US
Practice Address - Phone:978-685-5366
Practice Address - Fax:978-685-4867
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4975152W00000X
NH0877152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist