Provider Demographics
NPI:1275942419
Name:DESHAIES, JOHN (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DESHAIES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3758
Mailing Address - Country:US
Mailing Address - Phone:978-475-5252
Mailing Address - Fax:978-475-2226
Practice Address - Street 1:15 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3758
Practice Address - Country:US
Practice Address - Phone:978-475-5252
Practice Address - Fax:978-475-2226
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5034152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5034OtherMA LICENSE NUMBER