Healthcare Provider Details

I. General information

NPI: 1528174885
Provider Name (Legal Business Name): ATHOS BOUSVAROS MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

8 FRANCES RD
LEXINGTON MA
02421-7512
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-2962
  • Fax:
Mailing address:
  • Phone: 781-623-3956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number58765
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: