Healthcare Provider Details

I. General information

NPI: 1811965148
Provider Name (Legal Business Name): KALPANA PETHE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE PRIMARY CARE CENTER
BOSTON MA
02115-5724
US

IV. Provider business mailing address

3959 BROADWAY
NEW YORK NY
10032-1559
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6518
  • Fax: 617-730-0505
Mailing address:
  • Phone: 212-305-6227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number276486
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number238594
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: