Basic Information
Provider Information | |||||||||
NPI: | 1457340515 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GANSON-MYSHKIN | ||||||||
FirstName: | NATALIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2110 DORCHESTER AVE STE 311 | ||||||||
Address2: | SETON MEDICAL OFFICE BUILDING | ||||||||
City: | DORCHESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 021245615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6172960456 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2110 DORCHESTER AVE | ||||||||
Address2: |   | ||||||||
City: | DORCHESTER CENTER | ||||||||
State: | MA | ||||||||
PostalCode: | 021245628 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174363786 | ||||||||
FaxNumber: | 6172965778 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2005 | ||||||||
LastUpdateDate: | 09/02/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 75596 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | J12678 | 01 | MA | BLUE CROSS/BLUE SHIELD | OTHER | 3095347 | 05 | MA |   | MEDICAID | 64121 | 01 | MA | HARVARD PILGRIM HEALTHCAR | OTHER | B10065602 | 01 |   | CIGNA HEALTHCARE | OTHER | 075596 | 01 |   | TUFTS ASSOCIATED HEALTH P | OTHER |