Provider Demographics
NPI:1699742429
Name:CHASSE, MARK R (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:CHASSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:160 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2441
Mailing Address - Country:US
Mailing Address - Phone:860-635-6149
Mailing Address - Fax:860-632-1401
Practice Address - Street 1:160 WEST ST
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2441
Practice Address - Country:US
Practice Address - Phone:860-635-6149
Practice Address - Fax:860-632-1401
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT939152W00000X
MA2893152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4275439OtherAETNA
C01952OtherMEDICARE
090000939CT01OtherBLUE CROSS