Healthcare Provider Details

I. General information

NPI: 1952494759
Provider Name (Legal Business Name): MARK DERESIENSKI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HAMPTON WAY BLDG#1A
WAKEFIELD RI
02879-2553
US

IV. Provider business mailing address

175 PARAMOUNT DR SUITE 203
RAYNHAM MA
02767-1065
US

V. Phone/Fax

Practice location:
  • Phone: 401-783-7009
  • Fax: 401-789-3909
Mailing address:
  • Phone: 774-320-3040
  • Fax: 508-910-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODTG00475
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: