Provider Demographics
NPI:1932223922
Name:ORIGINAL GORDON OPTICAL COMPANY
Entity type:Organization
Organization Name:ORIGINAL GORDON OPTICAL COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NOAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHRIBER
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:781-861-8814
Mailing Address - Street 1:47 WALTHAM ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-5406
Mailing Address - Country:US
Mailing Address - Phone:781-861-8814
Mailing Address - Fax:781-860-7397
Practice Address - Street 1:47 WALTHAM ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-5406
Practice Address - Country:US
Practice Address - Phone:781-861-8814
Practice Address - Fax:781-860-7397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-17
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5332156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0854380002Medicare NSC
MA0854380002Medicare ID - Type UnspecifiedMEDICARE ID