1346560901 NPI number — DR. AMOLA SHERTUKDE BHAKTA D.O.

Table of content: DR. AMOLA SHERTUKDE BHAKTA D.O. (NPI 1346560901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346560901 NPI number — DR. AMOLA SHERTUKDE BHAKTA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHERTUKDE BHAKTA
Provider First Name:
AMOLA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHERTUKDE
Provider Other First Name:
AMOLA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346560901
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 MASSACHUSETTS AVENUE
Provider Second Line Business Mailing Address:
FL 2
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-2690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 COMMONWEALTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02215-1274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-414-6800
Provider Business Practice Location Address Fax Number:
617-414-6217
Provider Enumeration Date:
06/07/2010

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: 207Q00000X , with the licence number:  254877 , 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: 110093903A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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