Healthcare Provider Details

I. General information

NPI: 1316904782
Provider Name (Legal Business Name): ANTHONY VICTOR DAMICO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST ASB1 L2 BRIGHAM AND WOMENS HOSPITAL RADIATION ONCOLOGY
BOSTON MA
02115
US

IV. Provider business mailing address

375 BOYLSTON ST
BROOKLINE MA
02445-6007
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-6310
  • Fax:
Mailing address:
  • Phone: 857-307-0867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number79651
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: