Healthcare Provider Details

I. General information

NPI: 1740248970
Provider Name (Legal Business Name): MARK L WALTZMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 10/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHILDREN'S HOSPITAL BOSTON DIVISION OF EMERGENCY 300 LONGWOOD AVE
BOSON MA
02115
US

IV. Provider business mailing address

300 LONGWOOD AVE 300 LONGWOOD AVE
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6624
  • Fax:
Mailing address:
  • Phone: 617-355-6624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number153293
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number153293
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: