Healthcare Provider Details

I. General information

NPI: 1144385543
Provider Name (Legal Business Name): JOHN DAVIES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

147 MILK ST
BOSTON MA
02109-4806
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number35008
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: