Healthcare Provider Details

I. General information

NPI: 1962278523
Provider Name (Legal Business Name): IDG OF CAPE COD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 11/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FALMOUTH RD STE 101B
MASHPEE MA
02649-3303
US

IV. Provider business mailing address

PO BOX 590129
NEWTON CENTER MA
02459-0002
US

V. Phone/Fax

Practice location:
  • Phone: 617-783-7100
  • Fax: 617-783-7104
Mailing address:
  • Phone: 617-721-6552
  • Fax: 617-783-7104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK AMSTER
Title or Position: CHIEF PHYSICIAN
Credential: MD
Phone: 617-721-6552