Healthcare Provider Details

I. General information

NPI: 1982011862
Provider Name (Legal Business Name): NIKHIL MUKUND THATTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2014
Last Update Date: 04/17/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MASSACHUSETTS AVE. CROSSTOWN BLDG FL 7
BOSTON MA
02118
US

IV. Provider business mailing address

BMC PROVIDER ENROLLMENT OFFICE 960 MASSACHUSETTS AVE,.2ND FLOOR
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4841
  • Fax:
Mailing address:
  • Phone: 617-414-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number270796
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number270796
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: