Healthcare Provider Details

I. General information

NPI: 1144700535
Provider Name (Legal Business Name): NADIM JIWA MB BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 FENWOOD RD
BOSTON MA
02115-6128
US

IV. Provider business mailing address

74 MORAINE ST
BOSTON MA
02130-4308
US

V. Phone/Fax

Practice location:
  • Phone: 617-525-7846
  • Fax:
Mailing address:
  • Phone: 857-361-2347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number275077
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: