Healthcare Provider Details

I. General information

NPI: 1508001751
Provider Name (Legal Business Name): OTTIE M THOMAS-SMITH BCO, CCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 05/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 BOYLSTON ST
BOSTON MA
02199-7820
US

IV. Provider business mailing address

404 MOOSEHEAD TRL
JACKSON ME
04921-3314
US

V. Phone/Fax

Practice location:
  • Phone: 617-750-6273
  • Fax:
Mailing address:
  • Phone: 207-722-3462
  • Fax: 207-722-3320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: