Healthcare Provider Details

I. General information

NPI: 1962451591
Provider Name (Legal Business Name): PREVENTIVE MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 KENT ST
BROOKLINE MA
02445-7901
US

IV. Provider business mailing address

11 KENT ST
BROOKLINE MA
02445-7901
US

V. Phone/Fax

Practice location:
  • Phone: 617-383-6405
  • Fax:
Mailing address:
  • Phone: 617-383-6405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PUNYAMURTULA KISHORE
Title or Position: DIRECTOR
Credential: M.D.
Phone: 617-383-6567