Provider Demographics
NPI:1902188477
Name:VANN, DONNA (OD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:VANN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 YALE AVE
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-2309
Mailing Address - Country:US
Mailing Address - Phone:781-245-1871
Mailing Address - Fax:781-245-7963
Practice Address - Street 1:22 YALE AVE
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-2309
Practice Address - Country:US
Practice Address - Phone:781-245-1871
Practice Address - Fax:781-245-7963
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110090610AMedicaid
MA2421501Medicare PIN