Healthcare Provider Details

I. General information

NPI: 1871575548
Provider Name (Legal Business Name): NICOLA MOGAVERO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 MAIN ST
MELROSE MA
02176-2710
US

IV. Provider business mailing address

792 MAIN ST
MELROSE MA
02176-2710
US

V. Phone/Fax

Practice location:
  • Phone: 781-665-9066
  • Fax: 781-662-9758
Mailing address:
  • Phone: 781-665-9066
  • Fax: 781-662-9758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number81784
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: