Healthcare Provider Details

I. General information

NPI: 1912971284
Provider Name (Legal Business Name): RENATA RATUSZNIK-MARTIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVE YAWKEY 2
BOSTON MA
02118-4072
US

IV. Provider business mailing address

67 UNION ST # 303
NATICK MA
01760-7700
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-2080
  • Fax: 617-414-2090
Mailing address:
  • Phone: 617-414-4465
  • Fax: 617-414-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number159545
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: