1134183981 NPI number — MRS. MARY T HETTLER-YOUNG O.D.

Table of content: MRS. MARY T HETTLER-YOUNG O.D. (NPI 1134183981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134183981 NPI number — MRS. MARY T HETTLER-YOUNG O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HETTLER-YOUNG
Provider First Name:
MARY
Provider Middle Name:
T
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1134183981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 MIDDLESEX ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELLESLEY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02482-7022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-235-6532
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 WASHINGTON ST
Provider Second Line Business Practice Location Address:
# 450
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02111-1526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-636-4600
Provider Business Practice Location Address Fax Number:
617-636-4866
Provider Enumeration Date:
04/17/2006

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: 152W00000X , with the licence number:  3766 , 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: 0334201 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com