Basic Information
| Provider Information | |||||||||
| NPI: | 1962482190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VINTON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598374 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1611 CAMBRIDGE ST | ||||||||
| Address2: | PEDIATRICS DEPT | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021384302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176615575 | ||||||||
| FaxNumber: | 6176615134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 03/13/2012 | ||||||||
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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 | 208000000X | 59797 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0015160 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 059797 | 01 | MA | TUFTS | OTHER | J08188 | 01 | MA | BLUE CROSS | OTHER | PP508 | 01 | MA | HARVARD PILGRIM | OTHER | 3049434 | 05 | MA | MEDICAID |