Provider Demographics
NPI:1689870602
Name:STATE STREET EYE HEALTH ASSOCIATES
Entity Type:Organization
Organization Name:STATE STREET EYE HEALTH ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAVREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-742-7200
Mailing Address - Street 1:33 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4216
Mailing Address - Country:US
Mailing Address - Phone:617-742-7200
Mailing Address - Fax:617-742-7272
Practice Address - Street 1:33 BROAD ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-4216
Practice Address - Country:US
Practice Address - Phone:617-742-7200
Practice Address - Fax:617-742-7272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2665152W00000X
MA2352152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0336661Medicaid
MA0313351Medicaid
MA0336661Medicaid
MAT59193Medicare UPIN
MA142658Medicare ID - Type UnspecifiedHOWARD S. HARRISON,O.D.
MAT59261Medicare UPIN