Provider Demographics
NPI:1700498672
Name:KALLAMATA, ENIAN (OD, MS)
Entity Type:Individual
Prefix:
First Name:ENIAN
Middle Name:
Last Name:KALLAMATA
Suffix:
Gender:M
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BLUE JAY CIR
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02126-1994
Mailing Address - Country:US
Mailing Address - Phone:857-492-6188
Mailing Address - Fax:
Practice Address - Street 1:63 STATION LNDG
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-5192
Practice Address - Country:US
Practice Address - Phone:781-393-5367
Practice Address - Fax:617-453-5757
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5418152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist