Healthcare Provider Details

I. General information

NPI: 1619961968
Provider Name (Legal Business Name): THADDEUS P. DRYJA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 CHARLES ST
BOSTON MA
02114-3002
US

IV. Provider business mailing address

PO BOX 8010
BOSTON MA
02114-0916
US

V. Phone/Fax

Practice location:
  • Phone: 617-573-3319
  • Fax:
Mailing address:
  • Phone: 617-573-4458
  • Fax: 617-573-4037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number41891
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number41891
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: