MEDICARE: KRISTEN MARIE BANEK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0618001772	VA

General Provider Information

NPI Number	:	1790948420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN MARIE BANEK O.D.

Provider Business Mailing Address
First Line	:	372 WASHINGTON ST
Second Line	:
City	:	BRIGHTON
State	:	MA
Zip	:	02135-2725
Country	:	US
Telephone Number	:	617-782-6650
Fax Number	:	617-782-2660

Provider Business Practice Location Address
First Line	:	372 WASHINGTON ST
Second Line	:
City	:	BRIGHTON
State	:	MA
Zip	:	02135-2725
Country	:	US
Telephone Number	:	617-782-6650
Fax Number	:	617-782-2660

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	11/15/2013

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