Healthcare Provider Details

I. General information

NPI: 1760504880
Provider Name (Legal Business Name): MANISHA THAKURIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 LONGWOOD AVE
BOSTON MA
02115-5804
US

IV. Provider business mailing address

375 BOYLSTON ST
BROOKLINE MA
02445-6007
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-4918
  • Fax:
Mailing address:
  • Phone: 857-307-0867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number245821
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301088143
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: