Healthcare Provider Details

I. General information

NPI: 1770996068
Provider Name (Legal Business Name): ETHAN ANGLEMYER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE BCH 3222
BOSTON MA
02115
US

IV. Provider business mailing address

300 LONGWOOD AVE BCH 3222
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6680
  • Fax: 617-730-0319
Mailing address:
  • Phone: 617-355-6680
  • Fax: 617-730-0319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberUO3877
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number274620
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberOS15190
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number34.017599
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: