Healthcare Provider Details

I. General information

NPI: 1174907588
Provider Name (Legal Business Name): VIVIAN KARINA IBANEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CONDOR STREET
EAST BOSTON MA
02128
US

IV. Provider business mailing address

31 WARE ST.
DEDHAM MA
02026
US

V. Phone/Fax

Practice location:
  • Phone: 617-569-6560
  • Fax:
Mailing address:
  • Phone: 617-838-7287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number042317215
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: