Healthcare Provider Details

I. General information

NPI: 1861562217
Provider Name (Legal Business Name): WALTER POTAZNICK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

584A HIGH ST
DEDHAM MA
02026-1807
US

IV. Provider business mailing address

584 A HIGH STREET
DEDHAM MA
02026-1807
US

V. Phone/Fax

Practice location:
  • Phone: 781-471-4338
  • Fax: 781-471-4339
Mailing address:
  • Phone: 781-471-4339
  • Fax: 781-471-4339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberMA 2567T
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberMA 2567T
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberMA 2567T
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMA 2567T
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: