Healthcare Provider Details

I. General information

NPI: 1467594259
Provider Name (Legal Business Name): ANDRE DEJAM MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-6050
  • Fax: 617-421-6083
Mailing address:
  • Phone: 617-421-6050
  • Fax: 617-421-6083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number233927
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: