Provider Demographics
NPI:1609814177
Name:ICBAN, ELAINE (OD)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:
Last Name:ICBAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 COMMONWEALTH AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1274
Mailing Address - Country:US
Mailing Address - Phone:617-587-5511
Mailing Address - Fax:617-587-5514
Practice Address - Street 1:4199 WASHINGTON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02131-1733
Practice Address - Country:US
Practice Address - Phone:617-587-5520
Practice Address - Fax:617-587-5521
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4677152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA95191001OtherNETWORK HEALTH
MA7733882OtherAETNA
MA2988926OtherUNITED HEALTH CARE
MAAA131399OtherHARVARD PILGRIM