Provider Demographics
NPI:1790874667
Name:DICKERMAN, LAUREN (OD)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:
Last Name:DICKERMAN
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 1:19 DUNSTER ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5002
Mailing Address - Country:US
Mailing Address - Phone:617-354-5590
Mailing Address - Fax:
Practice Address - Street 1:19 DUNSTER ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5002
Practice Address - Country:US
Practice Address - Phone:617-354-5590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4211152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0334570Medicaid
MAW17335Medicare PIN