Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 4184 | MA |
NPI | 1225179070 |
---|---|
Provider Name | Mr. Edward G Pelham |
First Address | Boston, MA 02215-1274 |
Second Address | Boston, MA 02215 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2007 |
Last Update Date | 05/03/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0702374 | (05) | MA |
OP2440 | EYEMED (01) | MA |