Provider Demographics
NPI:1144369588
Name:EYECARE CENTER OF WATERBURY LLC
Entity type:Organization
Organization Name:EYECARE CENTER OF WATERBURY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PULASKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-754-8339
Mailing Address - Street 1:625 WOLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-1342
Mailing Address - Country:US
Mailing Address - Phone:203-754-8339
Mailing Address - Fax:
Practice Address - Street 1:625 WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-1342
Practice Address - Country:US
Practice Address - Phone:203-754-8339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000910335E00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0043160OtherAETNA
115526OtherEYEMED
762224OtherCONNECTICARE
OV8953OtherHEALTHNET
P379072OtherOXFORD
CT090000910CT01OtherBLUE CROSS
CT004257673Medicaid
115526OtherEYEMED