1528140985 NPI number — DAVID GOMOLIN M.D.

Table of content: DAVID GOMOLIN M.D. (NPI 1528140985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528140985 NPI number — DAVID GOMOLIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMOLIN
Provider First Name:
DAVID
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528140985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 PARKER HILL AVE
Provider Second Line Business Mailing Address:
STE 500
Provider Business Mailing Address City Name:
ROXBURY CROSSING
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02120-2847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-735-9200
Provider Business Mailing Address Fax Number:
617-735-9230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 PARKER HILL AVE
Provider Second Line Business Practice Location Address:
STE 500
Provider Business Practice Location Address City Name:
ROXBURY CROSSING
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02120-2847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-735-9200
Provider Business Practice Location Address Fax Number:
617-735-9230
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  49501 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2500375 . This is a "UNITED" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 708332 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3002772 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J02985 . This is a "BXBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 61469 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 226220 . This is a "BX OF RI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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