Provider Demographics
NPI:1902100795
Name:VISION SOURCE OF AMHERST AND GREENFIELD
Entity Type:Organization
Organization Name:VISION SOURCE OF AMHERST AND GREENFIELD
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:WINFIELD
Authorized Official - Last Name:WADMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:413-772-2571
Mailing Address - Street 1:489 BERNARDSTON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-1238
Mailing Address - Country:US
Mailing Address - Phone:413-772-2571
Mailing Address - Fax:413-772-2266
Practice Address - Street 1:489 BERNARDSTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-1238
Practice Address - Country:US
Practice Address - Phone:413-772-2571
Practice Address - Fax:413-772-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2012-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3258152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA17524OtherHEALTH NEW ENGLAND
MA409258OtherMEDICARE ID-TYPE UNSPECIFIED
MAY70858OtherBC/BS OF MA
MA000000021735OtherHEALTHNET BOSTON MEDICAL
MA0353787Medicaid
MAY70858OtherBC/BS OF MA
MA=========OtherUNITED HEALTH CARE
MA=========OtherAETNA - ALL
MA0353787Medicaid
MA17524OtherHEALTH NEW ENGLAND
MA=========OtherCOMMONWEALTH INDEMNITY PLAN
MA409258OtherMEDICARE ID-TYPE UNSPECIFIED
MA=========OtherCHILDRENS MEDICAL SECURITY
MA=========OtherCOMMONWEALTH INDEMNITY PLAN