Healthcare Provider Details

I. General information

NPI: 1457340515
Provider Name (Legal Business Name): NATALIA GANSON-MYSHKIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 DORCHESTER AVE
DORCHESTER CENTER MA
02124-5628
US

IV. Provider business mailing address

2110 DORCHESTER AVE STE 311 SETON MEDICAL OFFICE BUILDING
DORCHESTER MA
02124-5615
US

V. Phone/Fax

Practice location:
  • Phone: 617-436-3786
  • Fax: 617-296-5778
Mailing address:
  • Phone: 617-296-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number75596
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: