Provider Demographics
NPI:1790072650
Name:O'LEARY, KATHLEEN P (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:P
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-1630
Mailing Address - Country:US
Mailing Address - Phone:603-533-2774
Mailing Address - Fax:
Practice Address - Street 1:10 LINCOLN SQ
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1135
Practice Address - Country:US
Practice Address - Phone:508-373-5830
Practice Address - Fax:508-519-5512
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010471152W00000X, 152WP0200X
MA5008152W00000X
RIODTG00633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL502720046OtherMEDICARE PTAN
IL046010471Medicaid