Healthcare Provider Details

I. General information

NPI: 1114174257
Provider Name (Legal Business Name): MEDIATRIX MBAMALU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 02/28/2021
Certification Date: 02/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVE FL 6
BOSTON MA
02118-4001
US

IV. Provider business mailing address

801 ALBANY ST FL 1
BOSTON MA
02119-3791
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-6335
  • Fax:
Mailing address:
  • Phone: 617-414-6335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number275095
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: