Healthcare Provider Details

I. General information

NPI: 1285671875
Provider Name (Legal Business Name): MARK PUDER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE/FEGAN 3 CHILDREN'S HOSPITAL
BOSTON MA
02115
US

IV. Provider business mailing address

300 LONGWOOD AVENUE, 3RD FLOOR FEGAN BUILDING BOSTON CHILDREN'S HOSPITAL
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-3038
  • Fax:
Mailing address:
  • Phone: 617-355-1838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number73855
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: