Healthcare Provider Details

I. General information

NPI: 1730218181
Provider Name (Legal Business Name): BOAZ ITSHAKY MSOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2007
Last Update Date: 08/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 BEACON RD
BETHANY CT
06524
US

IV. Provider business mailing address

286 BEACON RD
BETHANY CT
06524-3080
US

V. Phone/Fax

Practice location:
  • Phone: 203-393-2773
  • Fax:
Mailing address:
  • Phone: 203-393-2773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number002459-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number000258
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: