Healthcare Provider Details

I. General information

NPI: 1659367472
Provider Name (Legal Business Name): THOMAS F FREDDO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF WATERLOO SCHOOL OF OPTOMETRY CLINICS 200 UNIVERSITY AVE, WEST
WATERLOO ONTARIO
N2L3G1
CA

IV. Provider business mailing address

116 SYLVIA'S LANE
WESTPORT MA
02790
US

V. Phone/Fax

Practice location:
  • Phone: 519-888-4567
  • Fax: 519-725-0784
Mailing address:
  • Phone: 617-636-6107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2578
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: