Healthcare Provider Details

I. General information

NPI: 1447258363
Provider Name (Legal Business Name): PAULA M MUTO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 AMESBURY ST SUITE 113
LAWRENCE MA
01840
US

IV. Provider business mailing address

198 MASSACHUSSETTS AVENUE SUITE 100
NORTH ANDOVER MA
01845
US

V. Phone/Fax

Practice location:
  • Phone: 978-685-5474
  • Fax: 978-689-0493
Mailing address:
  • Phone: 978-685-5474
  • Fax: 788-820-2369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number81002
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number81002
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3152464
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: