Provider Demographics
NPI:1952494759
Name:DERESIENSKI, MARK (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DERESIENSKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:175 PARAMOUNT DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1065
Mailing Address - Country:US
Mailing Address - Phone:774-320-3040
Mailing Address - Fax:508-910-2204
Practice Address - Street 1:20 HAMPTON WAY
Practice Address - Street 2:BLDG#1A
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-2553
Practice Address - Country:US
Practice Address - Phone:401-783-7009
Practice Address - Fax:401-789-3909
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIODTG00475152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006708Medicaid
RI7006708Medicaid
RI0070082221Medicare PIN
T53793Medicare UPIN