Provider Demographics
NPI:1588651061
Name:ODLE, ANDREA (OD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ODLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:FAUSTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:385 MENDON RD
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-2477
Mailing Address - Country:US
Mailing Address - Phone:401-762-4473
Mailing Address - Fax:
Practice Address - Street 1:385 MENDON RD
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-2477
Practice Address - Country:US
Practice Address - Phone:401-762-4473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0337030Medicaid
MAW17440Medicare PIN
MA410048924Medicare PIN
MAU91505Medicare UPIN