Provider Demographics
NPI:1669545323
Name:NINNEMAN, DONALD BRUCE (OD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:BRUCE
Last Name:NINNEMAN
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 1:100 BLUFF AVE
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-1644
Mailing Address - Country:US
Mailing Address - Phone:508-822-8626
Mailing Address - Fax:
Practice Address - Street 1:101 INDEPENDENCE MALL WAY
Practice Address - Street 2:LENS CRAFTERS
Practice Address - City:KINGSTON
Practice Address - State:MA
Practice Address - Zip Code:02364-3048
Practice Address - Country:US
Practice Address - Phone:781-588-7029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA152257OtherHARVARD PILGRIM
MA0313131Medicaid
MAW16148OtherBCBS
W17122Medicare ID - Type Unspecified