Provider Demographics
NPI:1922279637
Name:PUTNAM VISION CENTER
Entity Type:Organization
Organization Name:PUTNAM VISION CENTER
Other - Org Name:DAVID B GAUDREAU, O.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:INSURANCE/RECEPTIONEST
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:E
Authorized Official - Last Name:PELLERIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-963-2020
Mailing Address - Street 1:169 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2115
Mailing Address - Country:US
Mailing Address - Phone:860-963-2020
Mailing Address - Fax:860-928-2040
Practice Address - Street 1:169 GROVE ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2115
Practice Address - Country:US
Practice Address - Phone:860-963-2020
Practice Address - Fax:860-928-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP00086566Medicare PIN
CTT23111Medicare UPIN
CT0523550001Medicare NSC