1639183445 NPI number — DOMENIC VISOCCHI MSPT

Table of content: DOMENIC VISOCCHI MSPT (NPI 1639183445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639183445 NPI number — DOMENIC VISOCCHI MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VISOCCHI
Provider First Name:
DOMENIC
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1639183445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 HIGH ST
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02155-3860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-395-7333
Provider Business Mailing Address Fax Number:
781-395-7331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 HIGH ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-3860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-395-7333
Provider Business Practice Location Address Fax Number:
781-395-7331
Provider Enumeration Date:
07/28/2006

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: 2251X0800X , with the licence number:  15414 , 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: Y67923 . This is a "BCBS OF MASS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 469253 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y6860901 . This is a "MEDICARE P TAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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