Provider Demographics
NPI:1699228098
Name:DOW, REBECCA LYNN (LO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:DOW
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 GOLD STAR HWY
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3442
Mailing Address - Country:US
Mailing Address - Phone:860-449-0185
Mailing Address - Fax:860-449-0421
Practice Address - Street 1:150 GOLD STAR HWY
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3442
Practice Address - Country:US
Practice Address - Phone:860-449-0185
Practice Address - Fax:860-449-0421
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1727156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician