Healthcare Provider Details

I. General information

NPI: 1215501234
Provider Name (Legal Business Name): IVAN CANCAREVIC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 05/24/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS STREET
BOSTON MA
02115
US

IV. Provider business mailing address

75 FRANCIS STREET RENAL DIVISION, MEDICAL RESEARCH BUILDING, 4TH FLOOR
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5802
  • Fax:
Mailing address:
  • Phone: 617-732-5802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number3015633
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number3015633
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: