Provider Demographics
NPI:1871577254
Name:MACIASZEK, KIM MCGILLICUDDY (OD)
Entity type:Individual
Prefix:
First Name:KIM MCGILLICUDDY
Middle Name:
Last Name:MACIASZEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:426 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1850
Practice Address - Country:US
Practice Address - Phone:413-525-3010
Practice Address - Fax:413-525-7667
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3760152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA2839OtherHARVARD PILGRIM
410046213OtherRAILROAD MEDICARE
60892OtherFALLON COMMUNITY HEALTH
7252603OtherAETNA US HEALTHCARE
042472266015OtherTRICARE CHAMPUS
786726OtherMVP HEALTH CARE
MA0335622Medicaid
042472266OtherPRIVATE HEALTHCARE
042472266OtherTHREE RIVERS
2212894OtherFIRST HEALTH
8974875OtherCIGNA HEALTH PLAN
W16304OtherBLUE CARE ELECT
W17219OtherMEDICARE B
W16304OtherBLUE CARE ELECT
042472266OtherTHREE RIVERS