Healthcare Provider Details

I. General information

NPI: 1386709947
Provider Name (Legal Business Name): GREG ROSS WALDORF O.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LINCOLN SQ
WORCESTER MA
01608-1135
US

IV. Provider business mailing address

10 LINCOLN SQ
WORCESTER MA
01608-1135
US

V. Phone/Fax

Practice location:
  • Phone: 508-373-5830
  • Fax: 508-519-5512
Mailing address:
  • Phone: 508-373-5830
  • Fax: 508-519-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT5082
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODTGA00591
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: