Healthcare Provider Details

I. General information

NPI: 1134112733
Provider Name (Legal Business Name): RICHARD CHARLES MARTINO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 ANGELL BROOK DR
WEST BOYLSTON MA
01583-2120
US

IV. Provider business mailing address

144 ANGELL BROOK DR
WEST BOYLSTON MA
01583-2120
US

V. Phone/Fax

Practice location:
  • Phone: 774-261-8595
  • Fax: 774-261-8595
Mailing address:
  • Phone: 774-261-8595
  • Fax: 774-261-8595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2365
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: