Provider Demographics
NPI:1598709289
Name:O'DONOGHUE, MARK W (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:O'DONOGHUE
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:940 COMMONWEALTH AVE SUITE 2
Mailing Address - Street 2:NEW ENGLAND EYE INSTITUTE
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-587-5511
Mailing Address - Fax:617-236-6323
Practice Address - Street 1:930 COMMONWEALTH AVE SUITE 2A
Practice Address - Street 2:NEW ENGLAND EYE COMMONWEALTH
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-262-2020
Practice Address - Fax:617-236-6323
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-04-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA3023152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA62951OtherHARVARD PILGRAM
W15574OtherBLUE CROSS B S OF MA
152627OtherHARVARD PILGRAM HLTH CARE
MA0346322Medicaid
755398OtherTUFTS HEALTH PLAN
MA218458Medicare PIN
W15574OtherBLUE CROSS B S OF MA