Basic Information
| Provider Information | |||||||||
| NPI: | 1811045560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOSK | ||||||||
| FirstName: | FRIDA | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 ELIOT ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021302724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175242024 | ||||||||
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| Practice Location | |||||||||
| Address1: | 435 WARREN ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021191833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174427400 | ||||||||
| FaxNumber: | 6174278263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 158127 | MA | X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080P0006X | 158127 | MA | X | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1303961 | 05 | MA | MEDICAID |