Provider Demographics
NPI:1902188477
Name:VANN, DONNA (OD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:VANN
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 1:360 MERRIMACK ST
Mailing Address - Street 2:BLDG 9, ENTRANCE I
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1740
Mailing Address - Country:US
Mailing Address - Phone:978-688-6182
Mailing Address - Fax:978-689-0731
Practice Address - Street 1:360 MERRIMACK ST
Practice Address - Street 2:BLDG 9, ENTRANCE I
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1740
Practice Address - Country:US
Practice Address - Phone:978-688-6182
Practice Address - Fax:978-689-0731
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110090610AMedicaid
MA2421501Medicare PIN