Healthcare Provider Details

I. General information

NPI: 1396933826
Provider Name (Legal Business Name): DR ANTHONY W IRACA OF MEDFORD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 MYSTIC VALLEY PARKWAY
MEDFORD MA
02155
US

IV. Provider business mailing address

4110 MYSTIC VALLEY PARKWAY
MEDFORD MA
02155
US

V. Phone/Fax

Practice location:
  • Phone: 781-391-1195
  • Fax: 781-395-7875
Mailing address:
  • Phone: 781-391-1195
  • Fax: 781-395-7875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3432
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3432
License Number StateMA

VIII. Authorized Official

Name: DR. ANTHONY WALTER IRACA JR.
Title or Position: PRESIDENT
Credential: OD
Phone: 781-391-1195