Provider Demographics
NPI:1750410064
Name:MASS, MARTIN ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ALAN
Last Name:MASS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:33 SOUTHPOND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-2326
Mailing Address - Country:US
Mailing Address - Phone:860-728-5200
Mailing Address - Fax:860-728-5203
Practice Address - Street 1:86 PARK ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2524
Practice Address - Country:US
Practice Address - Phone:860-728-5200
Practice Address - Fax:860-728-5203
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000755152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004024139Medicaid
CT090000755CT02OtherBLUE CROSS & BLUE SHIELD
CT004024139Medicaid
CT090000755CT02OtherBLUE CROSS & BLUE SHIELD