Healthcare Provider Details

I. General information

NPI: 1205837176
Provider Name (Legal Business Name): TODD B ELLERIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6110
US

IV. Provider business mailing address

55 FOGG RD
WEYMOUTH MA
02190-2432
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5500
  • Fax:
Mailing address:
  • Phone: 781-340-3617
  • Fax: 781-340-3782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number210477
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: