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Provider Information for 1245539824

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1245539824

Calendar   Last Updated:  2017-04-17
  Certification Date: 


Name Value
NPI 1245539824
Enumeration Date 2011-03-22
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 450 BROOKLINE AVENUE LW-204
BOSTON, MA 02215
United States

Phone: | Fax:
View Map External Link
Primary Practice Address 450 BROOKLINE AVENUE
BOSTON, MA 02215
United States

Phone: 617-632-5042 | Fax: 617-582-9969
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 2080P0207X - Pediatrics Pediatric Hematology-Oncology MA 258121