Healthcare Provider Details

I. General information

NPI: 1649243221
Provider Name (Legal Business Name): TINA S CLEARY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 STANIFORD ST SUITE 600
BOSTON MA
02114-2517
US

IV. Provider business mailing address

50 STANIFORD ST SUITE 600
BOSTON MA
02114-2517
US

V. Phone/Fax

Practice location:
  • Phone: 617-367-4800
  • Fax: 617-723-7028
Mailing address:
  • Phone: 617-367-4800
  • Fax: 617-723-7028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number220298
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number220298
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: