Healthcare Provider Details

I. General information

NPI: 1720255482
Provider Name (Legal Business Name): IASON S MANTAGOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE FEGAN 4
BOSTON MA
02115
US

IV. Provider business mailing address

300 LONGWOOD AVE FEGAN 4
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6401
  • Fax: 617-730-0392
Mailing address:
  • Phone: 617-355-6401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number234820
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number234820
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: