NPIMap

Organization Active NPI

Lickteig Family Eyecare PC

  • Optometrist
  • Dedham, MA
National Provider Identifier
1063720498
Registry record updated Jun 13, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
4782 Issued in MA
Legal business name
LICKTEIG FAMILY EYECARE PC
Practice address
870 Providence Hwy
Dedham, MA 02026-6806
Phone
(781) 329-0067
Fax
(781) 320-5603
NPI assigned
Sep 20, 2010
Last updated
Jun 13, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 13, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Benjamin Thomas Lickteig, O.D.NPI 1962738286
Title
Owner
Phone
(781) 329-0067

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X 4782 MA Primary

Addresses

Primary practice location

870 Providence Hwy
Dedham, MA 02026-6806

Mailing address

870 Providence Hwy
Dedham, MA 02026-6806
Phone (781) 329-0067

Other identifiers 1

IdentifierTypeStateIssuer
0019618OtherMAMEDICARE PTAN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110203000603 MA Part B Supplier - Clinic/Group Practice 6002096328 Receives reassigned benefits from 14 practitioners
Practice locations: Dedham, MA; Natick, MA; Mansfield, MA; Medford, MA

National Provider Directory

National Provider Directory

Locations

280 School St
Ste J140
Mansfield, MA 02048
Phone (508) 594-4510

15 Brook St
Ste 3
Medfield, MA 02052

1245 Worcester St
Ste 1024
Natick, MA 01760
Phone (508) 653-0223

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1284940800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1307923200000",
    "number": "1063720498",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "870 PROVIDENCE HWY",
            "city": "DEDHAM",
            "state": "MA",
            "postal_code": "020266806",
            "telephone_number": "781-329-0067"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "870 PROVIDENCE HWY",
            "city": "DEDHAM",
            "state": "MA",
            "postal_code": "020266806",
            "telephone_number": "781-329-0067",
            "fax_number": "781-320-5603"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LICKTEIG FAMILY EYECARE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-09-20",
        "last_updated": "2011-06-13",
        "status": "A",
        "authorized_official_last_name": "LICKTEIG",
        "authorized_official_first_name": "BENJAMIN",
        "authorized_official_middle_name": "THOMAS",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "781-329-0067",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "MA",
            "license": "4782",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "0019618",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Dedham, MA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.