Healthcare Provider Details

I. General information

NPI: 1720228117
Provider Name (Legal Business Name): PREETI SUBRAMANYA SHASTRI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 10/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE STONEMAN 10
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVE STONEMAN 10
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-3940
  • Fax:
Mailing address:
  • Phone: 617-667-3940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number252866
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: