Healthcare Provider Details

I. General information

NPI: 1720615313
Provider Name (Legal Business Name): MIHOKO TANABE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MELNEA CASS BLVD
BOSTON MA
02119-4401
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE FL 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-2080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1013793
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: