Provider Demographics
NPI:1841674751
Name:WATERTOWN EYE GROUP, INC.
Entity type:Organization
Organization Name:WATERTOWN EYE GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSAKOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:617-285-4575
Mailing Address - Street 1:22 MCGRATH HWY # 4
Mailing Address - Street 2:C/O PEARLE VISION
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4508
Mailing Address - Country:US
Mailing Address - Phone:617-623-7522
Mailing Address - Fax:617-623-1326
Practice Address - Street 1:485 ARSENAL ST
Practice Address - Street 2:C/O PEARLE VISION
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-5091
Practice Address - Country:US
Practice Address - Phone:617-923-2022
Practice Address - Fax:617-923-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty