Provider Demographics
NPI:1780641357
Name:BRAITHWAITE, MARC L (OD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:L
Last Name:BRAITHWAITE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NEPONSET ST FL STREET12
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-836-8553
Mailing Address - Fax:508-832-5951
Practice Address - Street 1:385 SOUTHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2498
Practice Address - Country:US
Practice Address - Phone:508-856-9599
Practice Address - Fax:508-832-5951
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT903152W00000X
MDDA1826152W00000X
MA4997152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402872400Medicaid
ME433061299Medicaid
MDU96962Medicare UPIN
ME000885701Medicare PIN
ME433061299Medicaid