Healthcare Provider Details

I. General information

NPI: 1366495749
Provider Name (Legal Business Name): MARISA MODINI BOCHMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 ESSEX RD
IPSWICH MA
01938-2599
US

IV. Provider business mailing address

36 ESSEX ROAD
IPSWICH MA
01938
US

V. Phone/Fax

Practice location:
  • Phone: 978-356-5522
  • Fax: 978-356-0218
Mailing address:
  • Phone: 978-356-5522
  • Fax: 978-356-0218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number160017
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: