Healthcare Provider Details

I. General information

NPI: 1689773095
Provider Name (Legal Business Name): NANCY DETORA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MILLBURY ST
AUBURN MA
01501
US

IV. Provider business mailing address

105 MILLBURY ST
AUBURN MA
01501
US

V. Phone/Fax

Practice location:
  • Phone: 508-832-9691
  • Fax: 508-832-7670
Mailing address:
  • Phone: 508-832-9691
  • Fax: 508-832-7670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number48899
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3053997
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: