Basic Information
| Provider Information | |||||||||
| NPI: | 1083908685 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARDOOS | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 ALBANY ST FL G | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021193791 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 915 COMMONWEALTH AVE REAR | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022151394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173583400 | ||||||||
| FaxNumber: | 6173583710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2011 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 258669 | MA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 258669 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110103576A | 05 | MA | MEDICAID |