Provider Demographics
NPI:1700953783
Name:LEAHY, CHARLES (OD,MS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LEAHY
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 1:243 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3002
Mailing Address - Country:US
Mailing Address - Phone:617-573-4296
Mailing Address - Fax:
Practice Address - Street 1:243 CHARLES ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3002
Practice Address - Country:US
Practice Address - Phone:617-573-4296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3354152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAML0406327MOtherTPA LICENSE
MA3354OtherMA LICENSE