Healthcare Provider Details

I. General information

NPI: 1003875204
Provider Name (Legal Business Name): EARL H LIZOTTE JR. OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 MAIN ST
EASTHAMPTON MA
01027
US

IV. Provider business mailing address

176 MAIN ST
EASTHAMPTON MA
01027
US

V. Phone/Fax

Practice location:
  • Phone: 413-527-4881
  • Fax: 413-527-4892
Mailing address:
  • Phone: 413-527-4881
  • Fax: 413-527-4892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2057
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMA2057
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: