Healthcare Provider Details

I. General information

NPI: 1932670528
Provider Name (Legal Business Name): KSENIA PUTINTSEVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2018
Last Update Date: 12/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 CAMBRIDGE ST
BRIGHTON MA
02135-2907
US

IV. Provider business mailing address

225 FALLON RD APT 191
STONEHAM MA
02180-2904
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-2797
  • Fax:
Mailing address:
  • Phone:
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: