Provider Demographics
NPI:1942356449
Name:RUSSELL & JANE FRADKIN LLC
Entity Type:Organization
Organization Name:RUSSELL & JANE FRADKIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:FRADKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-234-6681
Mailing Address - Street 1:999 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:WHITINSVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01588-2123
Mailing Address - Country:US
Mailing Address - Phone:508-234-6681
Mailing Address - Fax:508-234-6507
Practice Address - Street 1:999 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:WHITINSVILLE
Practice Address - State:MA
Practice Address - Zip Code:01588-2123
Practice Address - Country:US
Practice Address - Phone:508-234-6681
Practice Address - Fax:508-234-6507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW20190OtherBC/BS
MA0230700001Medicare NSC
MA0230700001Medicare NSC
MA7979-8OtherBC/BS OF RHODE ISLAND