Oec Waterbury LLC
Organization Active NPI Optometrist · Waterbury, CT
NPI 1477097285 · NPPES record last updated Dec 13, 2016
Key facts
- NPI
- 1477097285
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Optometrist 152W00000X
- License
- 002346 (CT)
- Legal business name
- OEC WATERBURY LLC
- Practice address
- 3528 E Main St
Waterbury, CT 06705-3873 - Phone
- (203) 377-3934
- NPI assigned
- Dec 13, 2016
- Organization subpart
- Yes
- Parent organization (as reported)
- ORONOQUE EYE CARE INC
Authorized official
- Name
- Dr. Karen Bonnanzio, O.D.
- Title
- Member
- Phone
- (203) 377-3937
Parent organization (reported in NPPES) 1
Practitioners 4
-
Karen Grante Bonnanzio, O.D.
-
Kurt Joseph Tichy, O.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CT
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20170126001467 | CT | Part B Supplier - Clinic/Group Practice | 3173805116 |
Receives reassigned benefits from 4 practitioners Practice locations: Waterbury, CT |
National Provider Directory
- Part of
- Oronoque Eye Care Inc
Locations
3528 E Main St
Waterbury, CT 06705
Phone (203) 377-3934
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | 002346 | CT | Yes |
Addresses
Primary practice location
3528 E Main St
Waterbury, CT 06705-3873
Mailing address
7365 Main St
Stratford, CT 06614-1300
Phone (203) 377-3937
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 004160983 | Medicaid | CT |
NPI Registry JSON
{
"created_epoch": "1481587200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1481587200000",
"number": "1477097285",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7365 MAIN ST",
"city": "STRATFORD",
"state": "CT",
"postal_code": "066141300",
"telephone_number": "203-377-3937",
"fax_number": "888-741-0620"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3528 E MAIN ST",
"city": "WATERBURY",
"state": "CT",
"postal_code": "067053873",
"telephone_number": "203-377-3934"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "OEC WATERBURY LLC",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "ORONOQUE EYE CARE INC",
"enumeration_date": "2016-12-13",
"last_updated": "2016-12-13",
"status": "A",
"authorized_official_last_name": "BONNANZIO",
"authorized_official_first_name": "KAREN",
"authorized_official_title_or_position": "MEMBER",
"authorized_official_telephone_number": "203-377-3937",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "O.D."
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Optometrist",
"state": "CT",
"license": "002346",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "004160983",
"state": "CT"
}
],
"endpoints": [],
"other_names": []
}Other providers in Waterbury, CT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 13, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.