=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841674751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERTOWN EYE GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2015
-----------------------------------------------------
Last Update Date | 07/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 485 ARSENAL ST C/O PEARLE VISION
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02472-5091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-923-2022
-----------------------------------------------------
Fax | 617-923-2023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 MCGRATH HWY # 4 C/O PEARLE VISION
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02143-4508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-623-7522
-----------------------------------------------------
Fax | 617-623-1326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALEX RUSSAKOVSKY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 617-285-4575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4635
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------