Provider Demographics
NPI:1891747705
Name:VALENTINE, FREDERICK R JR
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:R
Last Name:VALENTINE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 G A R HWY
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-4501
Mailing Address - Country:US
Mailing Address - Phone:508-675-7725
Mailing Address - Fax:508-676-3079
Practice Address - Street 1:1044 G A R HWY
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-4501
Practice Address - Country:US
Practice Address - Phone:508-675-7725
Practice Address - Fax:508-676-3079
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0333158Medicaid
2200563OtherUNITED HEALTHCARE
MA151600OtherHARVARD PILGRIM
MA0333158Medicaid
MAT59281Medicare UPIN
MA0902300002Medicare NSC