Provider Demographics
NPI:1801241203
Name:GUEVARA, ANGHELO
Entity type:Individual
Prefix:
First Name:ANGHELO
Middle Name:
Last Name:GUEVARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1951
Mailing Address - Country:US
Mailing Address - Phone:617-425-2020
Mailing Address - Fax:617-425-2023
Practice Address - Street 1:1601 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-1951
Practice Address - Country:US
Practice Address - Phone:617-425-2020
Practice Address - Fax:617-425-2023
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6472156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6472OtherCOMMONWEALTH OF MASSACHUSETTS BOARD OF DISPENSING OPTICIANS