Healthcare Provider Details

I. General information

NPI: 1285373217
Provider Name (Legal Business Name): CHRISTIAN CARLO DELA CRUZ COSTALES DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 HARRISON AVE FL 5
BOSTON MA
02118-2309
US

IV. Provider business mailing address

732 HARRISON AVE FL 5
BOSTON MA
02118-2309
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-6840
  • Fax: 617-414-6710
Mailing address:
  • Phone: 617-414-6840
  • Fax: 617-414-6710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPDF8337
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: