Healthcare Provider Details

I. General information

NPI: 1588690960
Provider Name (Legal Business Name): GUL MOONIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE DEPT OF RADIOLOGY, NEURORADIOLOGY, WCCB-90
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVE DEPT OF RADIOLOGY, NEURORADIOLOGY, WCCB-90
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-754-2010
  • Fax:
Mailing address:
  • Phone: 617-754-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number276494
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberMD066340L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD066340L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: