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Provider Information for 1811339120

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: 1811339120

Calendar   Last Updated:  2015-10-04
  Certification Date: 


Name Value
NPI 1811339120
Enumeration Date 2013-07-28
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 665 WASHINGTON ST APT 2207
BOSTON, MA 02111-1636
United States

Phone: 617-505-9494 | Fax:
View Map External Link
Primary Practice Address 300 LONGWOOD AVE
BOSTON, MA 02115-5724
United States

Phone: 617-355-7252 | Fax:
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 2086S0122X - Surgery Plastic and Reconstructive Surgery MA 265091