Healthcare Provider Details

I. General information

NPI: 1093645806
Provider Name (Legal Business Name): DIEGO CARDOSO FRAGOSO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

20 CHAPEL ST APT A410
BROOKLINE MA
02446-7405
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6000
  • Fax:
Mailing address:
  • Phone: 617-680-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: