Provider Demographics
NPI:1184695561
Name:GONYEA, COLLEEN DAVEY (OD)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:DAVEY
Last Name:GONYEA
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 1:756 EASTFORD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-3940
Mailing Address - Country:US
Mailing Address - Phone:508-765-1373
Mailing Address - Fax:
Practice Address - Street 1:8 FEDERAL ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:508-791-9291
Practice Address - Fax:508-791-9292
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3836152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0369152Medicaid
U54744Medicare UPIN
MAW22029Medicare ID - Type Unspecified