Basic Information
Provider Information | |||||||||
NPI: | 1518204353 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEWTON WATERTOWN DERMATOLOGY ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 280 WASHINGTON ST | ||||||||
Address2: | SUITE #212 | ||||||||
City: | BRIGHTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021353511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177837100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 280 WASHINGTON ST | ||||||||
Address2: | SUITE #212 | ||||||||
City: | BRIGHTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021353511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177837100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2013 | ||||||||
LastUpdateDate: | 01/14/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AMSTER | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | STEWART | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
AuthorizedOfficialTelephone: | 6177837100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | 70448 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
ID | Type | State | Issuer | Description | J09362 | 01 | MA | MEDICARE | OTHER |