Healthcare Provider Details

I. General information

NPI: 1902008675
Provider Name (Legal Business Name): ALICIA A DEMIRJIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE INFECTIOUS DISEASES DIVISION
BOSTON MA
02115-5724
US

IV. Provider business mailing address

165 TREMONT ST UNIT 503
BOSTON MA
02111-1155
US

V. Phone/Fax

Practice location:
  • Phone: 617-919-2900
  • Fax:
Mailing address:
  • Phone: 617-818-7713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number228691
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: