Basic Information
| Provider Information | |||||||||
| NPI: | 1053584037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUNZALAN | ||||||||
| FirstName: | CARMI | ||||||||
| MiddleName: | SANTOS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTOS | ||||||||
| OtherFirstName: | CARMI | ||||||||
| OtherMiddleName: | MARTHA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 41 MALL ROAD | ||||||||
| Address2: | LAHEY HOSPITAL & MEDICAL CENTER | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448000 | ||||||||
| FaxNumber: | 7817445743 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 MALL ROAD | ||||||||
| Address2: | LAHEY HOSPITAL & MEDICAL CENTER | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448000 | ||||||||
| FaxNumber: | 7817445743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2008 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 262302 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RT0003X | 262302 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Transplant Hepatology | 207RG0100X | A140736 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0265551 | 05 | NJ | MEDICAID | 102614243 | 05 | PA | MEDICAID |