Provider Demographics
NPI:1659370526
Name:BOSTON OCULAR PROSTHETICS INC
Entity Type:Organization
Organization Name:BOSTON OCULAR PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAYLEE
Authorized Official - Middle Name:LIZABETH
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:BCO, CCA
Authorized Official - Phone:800-824-2492
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:
Mailing Address - City:SEARSPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04974-0245
Mailing Address - Country:US
Mailing Address - Phone:800-824-2492
Mailing Address - Fax:877-824-2413
Practice Address - Street 1:133 MORTLAND RD
Practice Address - Street 2:
Practice Address - City:SEARSPORT
Practice Address - State:ME
Practice Address - Zip Code:04974-0245
Practice Address - Country:US
Practice Address - Phone:207-352-5001
Practice Address - Fax:877-824-2413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1700X, 229N00000X, 332B00000X
MENO LICENSE REQUIRED332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologistGroup - Single Specialty
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA802828OtherTUFTS
ME005563OtherANTHEM INC MAINE
ME0597722OtherAETNA
NH30002787Medicaid
ME122680000Medicaid
MEM20271OtherCIGNA
NH30002787Medicaid