Healthcare Provider Details

I. General information

NPI: 1649604588
Provider Name (Legal Business Name): WINNIE W MOK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 SOUTH STREET
BOSTON MA
02111
US

IV. Provider business mailing address

145 SOUTH STREET
BOSTON MA
02111
US

V. Phone/Fax

Practice location:
  • Phone: 617-521-6730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number364658
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: