Healthcare Provider Details

I. General information

NPI: 1396875951
Provider Name (Legal Business Name): RICHARD BROSTOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MUZZEY ST
LEXINGTON MA
02421-5222
US

IV. Provider business mailing address

10 MUZZEY ST
LEXINGTON MA
02421-5222
US

V. Phone/Fax

Practice location:
  • Phone: 781-674-2069
  • Fax:
Mailing address:
  • Phone: 781-674-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: