Healthcare Provider Details

I. General information

NPI: 1346277696
Provider Name (Legal Business Name): VICTORIA GORODETSKY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CENTRE ST DEPARTMENT OF MEDICINE
BOSTON MA
02131-1011
US

IV. Provider business mailing address

63 DEPOT ST
WESTFORD MA
01886-1931
US

V. Phone/Fax

Practice location:
  • Phone: 617-363-8000
  • Fax:
Mailing address:
  • Phone: 978-692-1878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number253142
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: