Healthcare Provider Details

I. General information

NPI: 1124332994
Provider Name (Legal Business Name): MINA SEHIZADEH O.D., MSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1151
  • Fax: 617-421-8787
Mailing address:
  • Phone: 617-421-1151
  • Fax: 617-421-8787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4754
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: