Provider Demographics
NPI:1790720233
Name:ANOSIKE, GRACE E (OD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:ANOSIKE
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 1:79 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-1231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79 WINTER ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02141-1231
Practice Address - Country:US
Practice Address - Phone:617-905-8943
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3941152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0369802Medicaid
MAU67777Medicare UPIN
MA0369802Medicaid