Healthcare Provider Details

I. General information

NPI: 1114981073
Provider Name (Legal Business Name): IRINA Y MEZHEBOVSKY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SOUTH ST
BROOKLINE MA
02467-3658
US

IV. Provider business mailing address

44 HIGHLAND TER
NEEDHAM MA
02494-3014
US

V. Phone/Fax

Practice location:
  • Phone: 617-469-0300
  • Fax: 617-783-0395
Mailing address:
  • Phone: 781-455-6609
  • Fax: 781-455-6609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number150235
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: