Healthcare Provider Details

I. General information

NPI: 1285717801
Provider Name (Legal Business Name): ELEANOR R MENZIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 LONGWOOD AVE
BOSTON MA
02115-5728
US

IV. Provider business mailing address

30 NARDELL RD
NEWTON MA
02459-2821
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7318
  • Fax: 617-277-7834
Mailing address:
  • Phone: 617-965-1881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number210151
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: