Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0800X | Contact Lens | 04MA1011 | MA |
N | 156FC0801X | Contact Lens Fitter | 04MA1011 | MA |
N | 156FX1800X | Optician | MA4511 | MA |
NPI | 1780727743 |
---|---|
Provider Name | Mr. Peter Maly |
First Address | Charlton, MA 01507-0194 |
Second Address | Charlton, MA 01507 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1535668 | MASSHEALTH (01) | MA |