Healthcare Provider Details

I. General information

NPI: 1205827789
Provider Name (Legal Business Name): DOUGLAS L TEICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVENUE
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVENUE
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-754-2009
  • Fax: 617-754-2004
Mailing address:
  • Phone: 617-754-2009
  • Fax: 617-754-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number55316
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: