Healthcare Provider Details

I. General information

NPI: 1982695284
Provider Name (Legal Business Name): MANUEL N PACHECO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WASHINGTON ST TUFTS MEDICAL CENTER BOX 1007
BOSTON MA
02111-1552
US

IV. Provider business mailing address

PO BOX 440304
WEST SOMERVILLE MA
02144-0027
US

V. Phone/Fax

Practice location:
  • Phone: 617-872-6522
  • Fax: 617-876-9998
Mailing address:
  • Phone: 617-872-6522
  • Fax: 617-876-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number216680
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number216680
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number216680
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: