Basic Information
| Provider Information | |||||||||
| NPI: | 1568557775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NORONHA | ||||||||
| FirstName: | ANSU | ||||||||
| MiddleName: | MAMMEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAMMEN | ||||||||
| OtherFirstName: | ANSU | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 HARRISON AVE # DOB503 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 830 HARRISON AVENUE | ||||||||
| Address2: | MOAKLEY, 2ND FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176386525 | ||||||||
| FaxNumber: | 6176387448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/21/2019 | ||||||||
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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 | 207R00000X | 226565 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 226565 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 110083854A | 05 | MA | MEDICAID |