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Provider Information for 1841492881

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: 1841492881

Calendar   Last Updated:  2008-06-03
  Certification Date: 


Name Value
NPI 1841492881
Enumeration Date 2007-06-01
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 241 PERKINS ST UNIT J502
JAMAICA PLAIN, MA 02130-4051
United States

Phone: 617-710-6919 | Fax:
View Map External Link
Primary Practice Address 300 LONGWOOD AVE HU-158
BOSTON, MA 02115-5724
United States

Phone: 617-355-7252 | Fax: 617-738-1657
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 235464
No 2086S0122X - Surgery Plastic and Reconstructive Surgery MA 211042