Provider Demographics
NPI:1588613806
Name:OPTOMETRIC PROVIDERS INC
Entity Type:Organization
Organization Name:OPTOMETRIC PROVIDERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALERINO
Authorized Official - Middle Name:M
Authorized Official - Last Name:IACOBBO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-446-3145
Mailing Address - Street 1:2921 ERIE BLVD E
Mailing Address - Street 2:OPTOMETRIC PROVIDERS INC
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224
Mailing Address - Country:US
Mailing Address - Phone:315-446-3145
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:1168 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-547-6080
Practice Address - Fax:617-576-9223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9781048Medicaid
MA9781048Medicaid