Provider Demographics
NPI:1992883136
Name:MEDFORD OPTICAL SHOP, INC.
Entity type:Organization
Organization Name:MEDFORD OPTICAL SHOP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-391-8222
Mailing Address - Street 1:16 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3820
Mailing Address - Country:US
Mailing Address - Phone:781-391-8222
Mailing Address - Fax:781-395-0311
Practice Address - Street 1:16 HIGH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3820
Practice Address - Country:US
Practice Address - Phone:781-391-8222
Practice Address - Fax:781-395-0311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1750332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0267030001Medicare ID - Type Unspecified