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NPI Code Detail

MEDICARE: DR. AZADEH SUPPAPPOLA O.D.

MEDICARE: DR. AZADEH SUPPAPPOLA O.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist4975MA
2152W00000XOptometrist0877NH

General Provider Information

NPI Number : 1538500202
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. AZADEH SUPPAPPOLA O.D.
Provider Business Mailing Address
First Line : 495 WESTERN AVE
Second Line :
City : BRIGHTON
State : MA
Zip : 02135-1007
Country : US
Telephone Number : 617-783-0500
Fax Number :
Provider Business Practice Location Address
First Line : 495 WESTERN AVE
Second Line :
City : BRIGHTON
State : MA
Zip : 02135-1007
Country : US
Telephone Number : 617-783-0500
Fax Number : 617-562-1398
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/10/2013
Last Update Date : 04/10/2026

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