Provider Demographics
NPI:1831253947
Name:FISHLYN, LEON (OD)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:FISHLYN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 GREAT RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-5712
Mailing Address - Country:US
Mailing Address - Phone:978-263-5255
Mailing Address - Fax:978-263-8832
Practice Address - Street 1:163 GREAT RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-5712
Practice Address - Country:US
Practice Address - Phone:978-263-5255
Practice Address - Fax:978-263-8832
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2974152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA464758Medicare ID - Type UnspecifiedMEDICARE
MA152759Medicare UPIN
MA94140Medicare UPIN
MA21423Medicare UPIN
MA461495Medicare UPIN
MAW22046Medicare UPIN
MA5196597Medicare UPIN