Provider Demographics
NPI:1134183981
Name:HETTLER-YOUNG, MARY T (OD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:T
Last Name:HETTLER-YOUNG
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 1:4 MIDDLESEX ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-7022
Mailing Address - Country:US
Mailing Address - Phone:781-235-6532
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINGTON ST
Practice Address - Street 2:# 450
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-4600
Practice Address - Fax:617-636-4866
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3766152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0334201Medicaid
MAU82667Medicare UPIN
MA0334201Medicaid