Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 5980 | MA |
NPI | 1013348614 |
---|---|
Provider Name | Sergey Zotov |
First Address | Watertown, MA 02472-5091 |
Second Address | Watertown, MA 02472-5091 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2013 |
Last Update Date | 06/12/2013 |