Healthcare Provider Details

I. General information

NPI: 1770314726
Provider Name (Legal Business Name): GINA LOUISE DESTEFANO OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MAN MAR DR UNIT 2
PLAINVILLE MA
02762-2272
US

IV. Provider business mailing address

1797 WASHINGTON ST
HOLLISTON MA
01746-2239
US

V. Phone/Fax

Practice location:
  • Phone: 508-222-9914
  • Fax: 508-222-9914
Mailing address:
  • Phone: 774-573-6307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT8361
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number011050
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: