Provider Demographics
NPI:1346229655
Name:POTVIN, LAURA ANNE
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANNE
Last Name:POTVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 SALEM ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:GROVELAND
Mailing Address - State:MA
Mailing Address - Zip Code:01834-1565
Mailing Address - Country:US
Mailing Address - Phone:978-374-8991
Mailing Address - Fax:
Practice Address - Street 1:939 SALEM ST
Practice Address - Street 2:SUITE 7
Practice Address - City:GROVELAND
Practice Address - State:MA
Practice Address - Zip Code:01834-1565
Practice Address - Country:US
Practice Address - Phone:978-374-8991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3365152W00000X, 152WC0802X, 152WP0200X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA353833Medicaid
MAW21021Medicare ID - Type Unspecified
MA353833Medicaid