Provider Demographics
NPI:1801896824
Name:CARLSON, NANCY (OD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3468
Mailing Address - Country:US
Mailing Address - Phone:617-262-2020
Mailing Address - Fax:617-236-6323
Practice Address - Street 1:1255 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3468
Practice Address - Country:US
Practice Address - Phone:617-262-2020
Practice Address - Fax:617-236-6323
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2619152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0384411Medicaid
MA0384411Medicaid
U02216Medicare UPIN