Healthcare Provider Details

I. General information

NPI: 1578640678
Provider Name (Legal Business Name): THERESA J RUGGIERO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 MASONIC STREET
NORTHAMPTON MA
01060-1833
US

IV. Provider business mailing address

86 MASONIC STREET
NORTHAMPTON MA
01060-1833
US

V. Phone/Fax

Practice location:
  • Phone: 413-586-5002
  • Fax: 413-586-4769
Mailing address:
  • Phone: 413-586-5002
  • Fax: 413-586-4769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number04-3192348
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number04-3192348
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number04-3192348
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: