Basic Information
Provider Information | |||||||||
NPI: | 1912359811 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AUSTRIA | ||||||||
FirstName: | OLIVER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 265 CHELMSFORD ST | ||||||||
Address2: |   | ||||||||
City: | CHELMSFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 018242332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9782561717 | ||||||||
FaxNumber: | 9782567101 | ||||||||
Practice Location | |||||||||
Address1: | 55 DIMOCK ST | ||||||||
Address2: |   | ||||||||
City: | ROXBURY | ||||||||
State: | MA | ||||||||
PostalCode: | 021191029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174428800 | ||||||||
FaxNumber: | 6175410950 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2016 | ||||||||
LastUpdateDate: | 07/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 1223G0001X | DN1858367 | MA | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 122300000X | 05 | MA |   | MEDICAID |