Healthcare Provider Details

I. General information

NPI: 1518215128
Provider Name (Legal Business Name): MOTAHARSADAT HOSSEINI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-3726
  • Fax:
Mailing address:
  • Phone: 617-726-3726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberP28025
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number67209
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number1015861
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: