Provider Demographics
NPI:1356385272
Name:ST PETER, JASON THOMAS (OD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
Last Name:ST PETER
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 1:888 WORCESTER ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-3744
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:339-686-2561
Practice Address - Street 1:438 MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3396
Practice Address - Country:US
Practice Address - Phone:888-964-6681
Practice Address - Fax:888-662-0859
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4065152W00000X
CT002465152W00000X
NH0847152W00000X
NYTUV005854-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004261210Medicaid
NY02865598Medicaid
NH3074722Medicaid
MA110014741AMedicaid
MAW16242OtherBCBS
NYC528FCA121Medicare PIN
NY02865598Medicaid
CT410001174Medicare PIN
MA110014741AMedicaid
NH3074722Medicaid