Provider Demographics
NPI:1780707901
Name:GRAY PICKETT, AIMEE KOREN (OD)
Entity type:Individual
Prefix:
First Name:AIMEE
Middle Name:KOREN
Last Name:GRAY PICKETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AIMEE
Other - Middle Name:KOREN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:40 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4884
Mailing Address - Country:US
Mailing Address - Phone:508-746-8600
Mailing Address - Fax:508-747-0824
Practice Address - Street 1:40 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4884
Practice Address - Country:US
Practice Address - Phone:508-746-8600
Practice Address - Fax:508-747-0824
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004182152W00000X
MA4197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
900E06513OtherBCBS
MAAA227707OtherHARVARD PILGRIM
MA110014827AMedicaid
110955OtherEYE MED
MAW1736901OtherMEDICARE, NHIC
MA7368965OtherCIGNA
0552080001Medicare ID - Type Unspecified
MA7368965OtherCIGNA