Basic Information
| Provider Information | |||||||||
| NPI: | 1467420190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINKOFF | ||||||||
| FirstName: | OLGA | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 CONCORD AVE | ||||||||
| Address2: | STE 4100 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021381041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178648822 | ||||||||
| FaxNumber: | 6174919153 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 CONCORD AVE | ||||||||
| Address2: | STE 4100 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021381040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178648822 | ||||||||
| FaxNumber: | 6174919153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 48059 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME96893 | 01 | FL | LICENSE | OTHER | 235872 | 01 | MA | MA LICENSE | OTHER |