Healthcare Provider Details

I. General information

NPI: 1598709289
Provider Name (Legal Business Name): MARK W O'DONOGHUE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 COMMONWEALTH AVE SUITE 2A NEW ENGLAND EYE COMMONWEALTH
BOSTON MA
02215
US

IV. Provider business mailing address

940 COMMONWEALTH AVE SUITE 2 NEW ENGLAND EYE INSTITUTE
BOSTON MA
02215
US

V. Phone/Fax

Practice location:
  • Phone: 617-262-2020
  • Fax: 617-236-6323
Mailing address:
  • Phone: 617-587-5511
  • Fax: 617-236-6323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3023
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: