=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083095806
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY BUI VO O.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2015
-----------------------------------------------------
Last Update Date | 12/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1219 HANCOCK ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02169-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-481-1857
-----------------------------------------------------
Fax | 617-481-5278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1219 HANCOCK ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02169-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2944
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 5318
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------