Basic Information
| Provider Information | |||||||||
| NPI: | 1760019459 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KOBZEVA-HERZOG | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | JACQUELINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72 EAST CONCORD STREET | ||||||||
| Address2: | COLLAMORE BUILDING, C515 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388442 | ||||||||
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| Practice Location | |||||||||
| Address1: | 72 EAST CONCORD STREET | ||||||||
| Address2: | COLLAMORE BUILDING, C515 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388442 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2020 | ||||||||
| LastUpdateDate: | 07/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 285405 | MA | Y | Allopathic & Osteopathic Physicians | Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.