Provider Demographics
NPI:1669592127
Name:CAMMISA, JOHN III (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:CAMMISA
Suffix:III
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 1:56 GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHWICK
Mailing Address - State:MA
Mailing Address - Zip Code:01077-9213
Mailing Address - Country:US
Mailing Address - Phone:413-569-5547
Mailing Address - Fax:
Practice Address - Street 1:1624 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1224
Practice Address - Country:US
Practice Address - Phone:413-737-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3583152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW15914OtherBLUE CROSS,SHIELD,HMOBLUE
MA0391751Medicaid
MA463758Medicare ID - Type Unspecified