Healthcare Provider Details

I. General information

NPI: 1164438586
Provider Name (Legal Business Name): COLLEEN A MONAGHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 BICKFORD ST
JAMAICA PLAIN MA
02130-1401
US

IV. Provider business mailing address

107 MARIVISTA AVE
WALTHAM MA
02451-3062
US

V. Phone/Fax

Practice location:
  • Phone: 617-971-2100
  • Fax:
Mailing address:
  • Phone: 781-899-2956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number205295
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number205295
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: