Healthcare Provider Details

I. General information

NPI: 1538510318
Provider Name (Legal Business Name): LEONID DEMIHOVSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 SOUTHBRIDGE ST
WORCESTER MA
01608-2019
US

IV. Provider business mailing address

38 SOUTHBRIDGE ST
WORCESTER MA
01608-2019
US

V. Phone/Fax

Practice location:
  • Phone: 508-791-9291
  • Fax: 508-791-9292
Mailing address:
  • Phone: 508-791-9291
  • Fax: 508-791-9292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number5477
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number5477
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number5477
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: