Healthcare Provider Details

I. General information

NPI: 1942290671
Provider Name (Legal Business Name): SOJA PARK BENNETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PARKMAN ST PEDIATRIC ALLERGY YAW 6C
BOSTON MA
02114-3117
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2909
  • Fax: 617-724-0581
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number73633
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number73633
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: