Healthcare Provider Details

I. General information

NPI: 1487751491
Provider Name (Legal Business Name): PROMILA MATHUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 SOUTH ST #100
NORTHBORO MA
01532
US

IV. Provider business mailing address

27 SOUTH ST #100
NORTHBORO MA
01532
US

V. Phone/Fax

Practice location:
  • Phone: 508-393-2999
  • Fax: 508-393-3243
Mailing address:
  • Phone: 508-393-2999
  • Fax: 508-393-3243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number44512
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: