Provider Demographics
NPI:1962131706
Name:GAGLIARDI, MELYNDA MADISON
Entity type:Individual
Prefix:
First Name:MELYNDA
Middle Name:MADISON
Last Name:GAGLIARDI
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 1:1440 BEACON ST APT 401
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-2013
Mailing Address - Country:US
Mailing Address - Phone:954-235-0709
Mailing Address - Fax:
Practice Address - Street 1:930 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1274
Practice Address - Country:US
Practice Address - Phone:617-262-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA5577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program