Healthcare Provider Details

I. General information

NPI: 1265675292
Provider Name (Legal Business Name): IKA NOVIAWATY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 07/08/2024
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 ALBANY STREET, SUITE 7B SHAPIRO BUILDING
BOSTON MA
02118
US

IV. Provider business mailing address

960 MASSACHUSETTS AVENUE FL 2
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-8456
  • Fax: 617-638-8465
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number265068
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number265068
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number265068
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: