Healthcare Provider Details

I. General information

NPI: 1902992886
Provider Name (Legal Business Name): JOHN MARK ABBONDANZA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 TURNPIKE RD SUITE 7
SOUTHBOROUGH MA
01772-2114
US

IV. Provider business mailing address

30 TURNPIKE RD SUITE 7
SOUTHBOROUGH MA
01772-2114
US

V. Phone/Fax

Practice location:
  • Phone: 508-481-8558
  • Fax: 508-848-3057
Mailing address:
  • Phone: 508-481-8558
  • Fax: 508-848-3057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3407
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number3407
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number3407
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: