Provider Demographics
NPI:1306939111
Name:PETRONE, RICHARD MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:PETRONE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LAHEY CLINIC
Mailing Address - Street 2:ONE ESSEX CTR DR
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960
Mailing Address - Country:US
Mailing Address - Phone:978-538-4440
Mailing Address - Fax:
Practice Address - Street 1:LAHEY CLINIC
Practice Address - Street 2:ONE ESSEX CENTER DRIVE
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960
Practice Address - Country:US
Practice Address - Phone:978-538-4416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2993152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110016054AMedicaid
MAW1599202Medicare PIN