Basic Information
Provider Information | |||||||||
NPI: | 1811987548 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | DRUCILLA | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9142 | ||||||||
Address2: |   | ||||||||
City: | CHARLESTOWN | ||||||||
State: | MA | ||||||||
PostalCode: | 021299142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177240287 | ||||||||
FaxNumber: | 6177262894 | ||||||||
Practice Location | |||||||||
Address1: | 55 FRUIT ST | ||||||||
Address2: | WRN 2 | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021142696 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177241415 | ||||||||
FaxNumber: | 6177267474 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 58161 | MA | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
ID | Type | State | Issuer | Description | 3088774 | 05 | MA |   | MEDICAID | J12166 | 01 | MA | BCBS MA | OTHER | 730646 | 01 | MA | TUFTS HEALTH PLAN | OTHER |