Healthcare Provider Details

I. General information

NPI: 1750436150
Provider Name (Legal Business Name): DEREK JASON STILES PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LONGWOOD AVE THIRD FLOOR
BOSTON MA
02115
US

IV. Provider business mailing address

333 LONGWOOD AVE THIRD FLOOR
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6461
  • Fax: 312-942-7068
Mailing address:
  • Phone: 617-355-6461
  • Fax: 312-942-7068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2119
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147.001329
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: